Impacts of early childhood caries on the mental development

Abstract

Background

Early childhood caries (ECC) is a widespread public health issue influencing the children’s growth, development and quality of life. ECC-induced pain may provoke premature tooth loss, esthetical concerns and cognitive well-being. Notwithstanding the raising manifestations of the relationship between oral and mental health, impacts of ECC on children’s cognitive development have not been researched yet. The present study aimed to investigate the correlation between ECC and mental development.

Materials and methods

The current descriptive study involved 150 children assessed using age-specific forms: ASQ^®-TR forms for 36-month (34 mo 16 d–38 mo 30 d), 42-month (39 mo 0 d–44 mo 30 d), and 48-month (45 mo 0 d–50 mo 30 d) groups, and ASQ^®-SE-TR forms for 36-month (33–41 mo) and 48-month (42–53 mo) groups. Participants were categorized as having ECC, severe early childhood caries (sECC), or no dental caries. Obtained data were analyzed with SPSS^® v23. Categorical variables were presented as counts and percentages and the numerical ones as means and standard deviations. Kolmogrov-Simirnov and graphical tests were used to determine whether the numerical variables were normally distributed. Kruskal Wallis, Chi-square and Fisher’s test were implemented for comparisons. p < 0.05 was considered statistically significant.

Results

Age-dependent mean scores of ASQ^®-TR and ASQ-SE^® were found to be statistically indifferent (p > 0.05). Assessment of ASQ^®-TR results according to the age showed that risk scores of developmental delays were the highest among 48-months-old children (40.8%) and 42-month-old ones were at the greatest risk of developmental-disability (17%). In ASQ^®-SE-TR screening, the highest risk score of social-emotional problems (21.3%) was spotted among the 42-year-old age group. Higher rates of ASQ^®-TR risk and developmental delay scores were observed among the children with sECC than the caries-free ones in all three age groups (53.8%, 57.1% and 52.4% respectively). A similar relationship was found between the caries status and ASQ^®-TR results (p > 0.05). In all age groups, sECC impacted-children’s mean social emotional development scores (ASQ^®-SE-TR) were higher than the children with no caries, which was statistically significant in the 48 months-old age group (p < 0.05).

Conclusion

Given that ECC impacts not only growth, development, and quality of life but also social-emotional well-being, a prompt and effective ECC treatment is essential.

Introduction

Early childhood caries (ECC), as defined by the American Academy of Pediatric Dentistry (AAPD), is the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. It is recognized as a significant public health issue in both developed and developing countries [1]. Problems such as, ECC-related pain, infection, loss of orofacial functions, esthetic and speech disorders, premature tooth loss have a negative impact on the growth, development and quality life of the children [2]. Unilateral mastication, which is induced by food impaction-pain may lead to hypertrophy on the chewing side and atrophy on the non-chewing side, facial asymmetry, unilateral crossbite, and midline deviation of the dental arc [3]– [4].

Researchers have reported that mastification plays a major role in the stability of periodontal tissues, development of orofacial muscles, dental arch extension and stimulation of tooth eruption [5]. Also, approximal caries and space losses caused by premature extractions in the primary dentition result in orthodontic problems [6]. All these deformities observed in the children experiencing ECC may directly affect their daily social, psychological, and emotional well-being [7]. Accordingly, growing numbers of scientific studies in recent years have elucidated that oral health not only affected the physical but also mental wellness. However, no research has been conducted so far on the influence of ECC on mental health.

Studies investigating the correlation between the mental health and dental caries in adults have linked this situation to medication-induced xerostomia and insufficient oral hygiene mentally challenged individuals. Moreover, studies have reported increased levels of C-reactive protein (CRP) in the ones with dental decays [8], which might be associated with mental health issues [9].

Ages & Stages Questionnaire (ASQ^®) was designed for identifying the mental developmental progress in the children and ASQ-Social-Emotional (SE) was modeled for screening social-emotional development in the children (Paul H. Brookes Publishing Co., Inc. Baltimore, MD-USA).

The ASQ^®-TR is the Turkish adaptation of the ASQ^®, a parent-reported screening tool for children aged 3–72 months. It evaluates five developmental domains: communication, gross motor, fine motor, problem-solving, and personal-social development. Each domain includes six questions scored as “yes” (10 points), “sometimes” (5 points), or “not yet” (0 points), with results compared to age-specific cut-off points to determine developmental risk [10]. Similarly, the ASQ^®-SE-TR evaluates social-emotional skills, including self-regulation, compliance, affect, and peer interaction. Scores above age-specific thresholds may indicate the need for further evaluation. Both tools have been validated and are widely used in Türkiye [11]. Both are parent-centric screening tests for children in which developmental progresses are assessed in the early childhood. ASQ^® was adopted to Turkish (ASQ^®-TR) [10]. ASQ^®-Social-Emotional (SE) was also modified to Turkish (ASQ^®-SE-TR) [11]. Either are regarded as reliable and accurate developmental and social or emotional screening tools in Türkiye [12]– [13].

ECC-provoked pain and esthetic concerns may lead to psychological problems such as, low self-respect, social-exclusion and symptoms of depression. Moreover, chronic pain and treatment stress may adversely affect the mental health of the children by intensifying their anxiety. In light of these considerations, the study aimed to explore the association between mental development and early childhood caries (ECC), while also contributing to the clarification of this emerging topic in the literature.

Materials and methods

Study consent

This descriptive study involved 36–48 months-old children experienced severe early childhood caries (sECC), ECC and children with no dental caries who admitted to Ataturk University, Faculty of Dentistry, Department of Pedodontics between December 2024-January 2025.

All children were evaluated using ASQ^®-TR and ASQ^®-SE-TR before undergoing any dental treatment procedures. Developmental assessments were conducted in a calm, non-clinical setting to avoid anxiety or behavioral bias related to treatment.

Severe early childhood caries (sECC) is defined by the AAPD as the presence of any smooth-surface caries in children younger than 3 years. In children aged 3–5 years, sECC is diagnosed when there are dmft scores of ≥ 4 at age 3, ≥ 5 at age 4, or ≥ 6 at age 5, or when any caries affects the maxillary anterior teeth.

Ethical committee approval and official consents

This study was conducted by the Department of Pediatric Dentistry, Ataturk University in accordance with the provisions of Ministry of Health Clinical Researches Regulations and with the Ataturk University Faculty of Medicine Research Ethics Committee’s written approval (session No. B.30.2.ATA.0.01.00resolution #753/29.11.2024).

Patient recruitment and selection

Inclusion criteria

• ✔ 36–48 months-old children with or without ECC and being accompanied by their parents

Exclusion criteria

• ✔ Children whose parents are unwilling to participate

• ✔ Children with any systemic disease, which disturbs oral hygiene

• ✔ Mentally and physically challenged children

Sample sizing

The required sample size was determined using G*Power version 3.1.9.7. A priori power analysis was performed for a one-way ANOVA (fixed effects, omnibus, one-way) with three groups. The following parameters were used: effect size f = 0.25 (medium effect), α error probability = 0.05, power (1-β) = 0.80, and number of groups = 3. Based on these parameters, the minimum required total sample size was calculated as 159 participants. However, due to limited accessibility to eligible participants within the study timeframe, 150 children aged 36–48 months were included in the study: 50 with severe early childhood caries (sECC), 50 with ECC (with no more than 5 decayed teeth), and 50 healthy children without dental caries. Although the final sample size was slightly lower than the calculated minimum, it was considered sufficient to provide preliminary evidence for the research objective.

Data collection tool

Study data were obtained through;

1. Questionnaire forms involving the questions about socio-demographic characteristics of the children (educational level, socio-economic and employment status of the parents).

2. Forms including the patients’ dental examination records and oral hygiene behaviors.

3. ASQ^®-TR: Turkish adaptation of ASQ^® screening tool kit (Translation of Ages & Stages Questionnaires-ASQ^®, Second Edition, Bricker and Squires. ^© 1999 Brookes Publishing Co. Baltimore, MD-USA. Translated and adapted, with permission, by Egiten Kitap), which was prepared in an age-specific way for every children of different ages in early childhood [10].

4. ASQ^®-SE-TR: Turkish translation of Ages & Stages Questionnaires- Social-Emotional, Second Edition-ASQ^®:SE-2 (Squires et al. © 2002 Brookes Publishing Co. Baltimore, MD- USA. Translated and adapted, with permission, by Egiten Kitap.) [11].

Prior to completing the forms, parents received verbal instructions from a trained pediatric dentist. Any unclear items were explained in a standardized and neutral manner without influencing their responses.

Turkish Version of Ages and Stages Questionnaire (ASQ-TR)

ASQ^®-TR is the Turkish translation of the ASQ, which is a parent/caregiver-completed developmental screening tool for the children aged 3–72 months-old (apx. 5.5 years) and it is altered/modified for a better adherence to the structure of the Turkish language and culture to ensure conceptual and experiential equivalence. Similarly, it also includes five developmental domains (communication, fine motor, gross motor, problem solving and personal-social). With the exception of communication domain consisting of seven items, each skill area of ASQ-TR involves 6 questions with the responses of “yes”, “sometimes” or “not yet”, which are scored as 10, 5 and 0 relatively. There are different age-specific cutoff scores established for each domain. When total scores in each domain are above the cutoffs child’s development should be considered as normal but if one or more score are below the cutoff values child should be referred for further evaluation (Table 1) [10].

Table 1.

Cut-off values for ASQ^®-TR domains for 36-, 42-, and 48-month-old children

	36 months (34 mo. 16 d-38 mo 30 d)	42 months (39 mo. 0 d-44 mo 30 d)	48 months (45 mo. 0 d-50 mo 30 d)
Communication	37.5	47.5	42.5
Fine motor	42.5	42.5	37.5
Gross motor	32.5	37.5	42.5
Problem solving	37.5	42.5	37.5
Personal-social	32.5	37.5	42.5

mo months, d day

Three different versions of the ASQ^®-TR were administered based on age groups: the 36-month form (for children aged 34 months 16 days to 38 months 30 days), the 42-month form (39 months 0 days to 44 months 30 days), and the 48-month form (45 months 0 days to 50 months 30 days).

Turkish version of ages & stages questionnaires- social-emotional (ASQ-SE-TR)

 ASQ^®-SE-TR is a series of parent/caregiver-completed and age-specific questionnaires for assessing the development of children from 3 to 72 months in the social-emotional developmental areas of self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people. It consists of age-dependent questionnaires with 19–36 questions. Parents response to the question items as “often or always,” “sometimes,” “rarely or never” and this is a “concern”. Total scores above the analytical cutoff point (72.5) indicate that child has some risks for social-emotional development and should be referred for assessment [11].

For the ASQ^®-SE-TR, two forms were used: the 36-month version, covering children aged 33 to 41 months, and the 48-month version, covering ages 42 to 53 months.

Screening tests were administered to the children with ECC and to the healthy control group in a suitable and quiet room where the children could be observed spontaneously and parents completed the tests under the supervision of a sole researcher after their written consents have been obtained. Parents were asked to observe their children at home and then complete and return the questionnaires in case the questions/activities involving the skills, which the children never tried before or could not be elicited in the ASQ -room environment.

Oral examination

Dental examinations were performed in a dental chair unit (DCU), using a World Health Organization (WHO) community periodontal index (CPI) probe (WHO 973/80- Martin, Solingen, Germany) and under the light of DCU. One dentist performed oral examinations and a second one recorded the decayed teeth and oral hygiene status on the dental examination forms. dmf-t scores were calculated using the data obtained.

Statistical analysis

IBM SPSS v23 was used for analyzing the study data. Categorical variables were expressed as counts and percentages whereas the numerical ones as means and standard deviations. Normality of the numerical variables was determined with Kolmogrov-Simirnov and graphical tests. Kruskal Wallis test was used for comparing the non-normally distributed numerical data and Chi-square and Fisher’s exact tests were used to compare the categorical variables. P < 0.05 was considered as statistically significant.

Results

Socio-demographic characteristics of the participants were as follows: 48% girls and 52% boys with an age interval of 32.7% 36 months, 31.3% 42 months, and 36% 48 months. Approximately 80% of the ASQ^®-TR forms were completed by the mothers whereas 22% of the parents were high school graduates and 48.7% of them had a bachelor’s degree (Table 2). At baseline, the children in all three groups (ECC, sECC, and control) showed comparable physical characteristics such as age, gender, and weight. There were no statistically significant differences among groups in these variables (p > 0.05), ensuring comparability prior to developmental assessment.

Table 2.

Participants’ socio-demographic data

Variables	n	%
Gender
Girl	72	48.0
Boy	78	52.0
Age (months)
36 months	49	32.7
42 months	47	31.3
48 months	54	36.0
Parent
Mother	115	76.7
Father	35	23.3
Level of parental education
Literate	11	7.3
Elementary school	12	8.0
Middle school	20	13.3
High school	34	22.7
University	73	48.7

n Number

Age-specific mean scores of ASQ^®-TR developmental skills and ASQ-SE^® were found to be statistically similar (p > 0.05). Except the gross motor, higher scores were found in other developmental areas and lower scores were determined in the areas of emotional and social development for 48-months-old children (Table 3).

Table 3.

Participants’ ASQ^®-TR and ASQ^®-SE-TR scores

Age (Months)	ASQ®-TR Developmental Areas (Mean ± SD)					ASQ®-SE-TR (Mean ± SD)
	Communication	Gross Motor	Fine Motor	Problem Solving	Personal-Social	Emotional-Social
36	59.5 ± 11.8	55.6 ± 7.4	41.8 ± 15	50.6 ± 10.1	52.0 ± 8.7	45.1 ± 23.3
42	62.2 ± 8	54.9 ± 7	46.7 ± 12	49.2 ± 9.4	51.3 ± 8	44.2 ± 29.3
48	63.9 ± 9.8	55.1 ± 8.2	47.2 ± 4.3	53.3 ± 7.5	53.1 ± 9.7	43.2 ± 26.7

SD Standard deviation

In the present study, distribution of caries by age was also similar (p > 0.05). A higher sECC score (38.9%) was observed in 48 months-old participants than other age groups (Table 4).

Table 4.

Caries distribution by the age

Age (moths)	Caries Status	n	%
36	No caries	20	40.8
	ECC	16	32.7
	sECC	13	26.5
	Total	49	100.0
42	No caries	19	40.4
	ECC	14	29.8
	sECC	14	29.8
	Total	47	100.0
48	No caries	16	29.6
	ECC	17	31.5
	sECC	21	38.9
	Total	54	100.0

n Number

Assessment of ASQ^®-TR results by age illustrated that 48-months-old children had the highest risk of developmental delays (40.8%) and 42-month-olds had the greatest rate of developmental-disability (17%). The highest risk score (21.3%) of social-emotional problems were observed among the 42-year-old age group in ASQ^®-SE-TR (Table 5).

Table 5.

ASQ^®-TR and ASQ^®-SE-TR scores by age

Age (months)	ASQ®-TR and ASQ®-SE-TR scores
			n	%
36	ASQ®-TR	Normal	25	51.0
		Risk	20	40.8
		Developmental Delay	4	8.2
	ASQ®-SE-TR	Risk	7	14.3
		No-risk	42	85.7
	Total		49	100.0
42	ASQ®-TR	Normal	27	57.4
		Risk	12	25.5
		Developmental Delay	8	17.0
	ASQ®-SE-TR	Risk	10	21.3
		No-risk	37	78.7
	Total		47	100.0
48	ASQ®-TR	Normal	32	59.3
		Risk	17	31.5
		Developmental Delay	5	9.3
	ASQ®-SE-TR	Risk	11	20.4
		No-risk	43	79.6
	Total		54	100.0

Table 6 presents the results of comparison between age-specific caries status and ASQ^®-TR scores. Higher rates of risk and developmental delay scores were observed among the children with sECC than the caries-free ones in all age groups (53.8%, 57.1% and 52.4% respectively). There was a similar correlation between the caries status and ASQ^®-TR results (p > 0.05).

Table 6.

Comparison between caries status and ASQ^®-TR results of the participants in all age groups

Age (month)	Caries status	ASQ®-TR results
		Normal n (%)	Risk + DD n (%)	Total n (%)	P
36	None	10 (50)	10 (50)	20 (100)	KW = 0.85 p > 0.05
	ECC	9 (56.3)	7 (43.8)	16 (100)
	sECC	6 (46.2)	7 (53.8)	13 (100)
42	None	13 (68.4)	6 (31.6)	19 (100)	KW = 0.34 p > 0.05
	ECC	8 (57.1)	6 (42.9)	14 (100)
	sECC	6 (42.9)	8 (57.1)	14 (100)
48	None	12 (75)	4 (25)	16 (100)	KW = 0.24 p > 0.05
	ECC	10 (58.8)	7 (41.2)	17 (100)
	sECC	10(47.6)	11(52.4)	21(100)

DD Developmental delay

Cross-reference between the scores of ASQ^®-SE-TR and caries status of the participants revealed that children experiencing ECC + sECC in all age groups had higher risks (17%, 21.4% and 58.8% respectively) with no statistical difference (Table 7).

Table 7.

Cross-reference between the caries status and participants’ ASQ^®-TR scores in all age groups

Age (month)	Caries status	ASQ®-SE-TR
		Risk n (%)	No Risk n (%)	Total n (%)	P
36	No caries	2(10)	18(90)	20(100)	X2 = 0.50 p > 0.05*
	ECC + sECC	5(17.2)	24(82.8)	16(100)
42	No caries	4(21.1)	15(78.9)	19(100)	X2 = 0.01 p > 0.05*
	ECC + sECC	6 (21.4)	22(78.6)	28(100)
48	No caries	1(6.3)	15(25)	16(100)	X2 = 2.7 p > 0.05*
	ECC + sECC	10(58.8)	28(41.2)	38(100)

* Fisher’s Exact Test

In all age groups, distribution of ASQ^®-TR domain scores by caries status was found to be similar (p > 0.05). Mean social-emotional development scores (ASQ^®-SE-TR) of the children with sECC were higher than the children with no caries in all age groups, which was statistically significant in 48 months-old age group (p < 0.05), (Table 8).

Table 8.

Distribution of ASQ^®-TR and ASQ^®-SE-TR domain scores by caries status for all age groups

Age (Months)	Caries status	ASQ®-TR domain scores (Mean ± SD)					ASQ®-SE-TR (Mean ± SD)
		Communication	Gross Motor	Fine Motor	Problem Solving	Personal-Social	Emotional-social
36	None	61.5 ± 11.4	57.5 ± 4.4	44.2 ± 11.2	54.0 ± 8.5	51.7 ± 10.2	40.2 ± 22.7
	ECC	55.3 ± 12.9	53.7 ± 10.7	42.5 ± 12.9	47.1 ± 10.4	52.5 ± 8.3	53.1 ± 23.2
	sECC	61.9 ± 10.3	55.0 ± 5.7	43.8 ± 15.2	49.6 ± 11.1	51.9 ± 7.2	42.6 ± 23.4
	P	KW = 3.5 p > 0.05	KW = 2.5 p > 0.05	KW = 3.5 p > 0.05	KW = 0.1 p > 0.05	KW = 4.5 p > 0.05	KW = 2.3 p > 0.05
42	None	62.1 ± 8.5	56.1 ± 5.2	47.9 ± 12.1	51.1 ± 7.7	51.3 ± 7.2	33.4 ± 24.6
	ECC	62.1 ± 8.5	55.0 ± 7.8	48.6 ± 11.5	47.8 ± 12.6	49.2 ± 8.2	51.1 ± 37.5
	sECC	62.5 ± 7.2	53.2 ± 8.7	43.2 ± 12.6	48.2 ± 7.9	53.2 ± 7.2	52.1 ± 22.6
	P	KW = 1.8 p > 0.05	KW = 0.8 p > 0.05	KW = 1.8 p > 0.05	KW = 0.8 p > 0.05	KW = 1.6 p > 0.05	KW = 4.6 p > 0.05
48	None	65.6 ± 7.0	54.7 ± 9.5	50.9 ± 12.6	53.4 ± 6.2	55.0 ± 7.9	24.1 ± 18.5
	ECC	64.1 ± 11.0	55.8 ± 7.1	47.6 ± 14.5	54.7 ± 6.7	51.7 ± 12.6	44.4 ± 30.5
	sECC	62.3 ± 10.7	54.7 ± 8.4	44.1 ± 15.2	52.1 ± 9.0	52.6 ± 8.4	50.0 ± 25.5
	P	KW = 3.9 p > 0.05	KW = 0.1 p > 0.05	KW = 2.4 p > 0.05	KW = 0.7 p > 0.05	KW = 0.8 p > 0.05	KW = 9.7 p = 0.008

SD Standard deviation

The present study elucidated ASQ^®-TR risk and development delays in boy patients for all age groups and higher mean ASQ^®-SE-TR risk scores were found in the girls of all age groups except the 36-month-olds with no statistically significance (p > 0.05). Although the mean ASQ^®-TR risk and development delay scores were higher in the children whose parents had a middle school degree or less, with no statistically significant difference (p > 0.05).

According to ASQ^®-SE-TR results the highest risk of social-emotional development was observed among the participants with middle school or less parental education level in 36 month-age group (26.7%) and among the children of the high school-educated families in 42 and 48 months-age groups, showing no statistically significant difference (p > 0.05), (Table 9).

Table 9.

Age-based distribution of ASQ^®-TR and ASQ^®-SE-TR scores by the participants’ demographic characteristics

Age (Months)	Demographics	ASQ®-TR			ASQ®-SE-TR
		Normal n (%)	Risk + DD n (%)	Total n (%)	Risk n (%)	No risk n (%)	Total n (%)
36	Gender
	Girl	12(57.1)	9(42.9)	21 (100)	2 (9.5)	19 (90.5)	21 (100)
	Boy	13(46.4)	15(53.6)	28 (100)	5 (17.9)	23 (82.1)	28(100)
	P	X2=0.5 p>0.05			X2=0.7 p>0.05
	Level of parental education**
	Middle school or less	3 (20.0)	12(80.0)	15(100)	4 (26.7)	11(73.3)	15(100)
	High School	6(66.7)	3 (33.3)	9(100)	1 (11.1)	8 (88.9)	9(100)
	University	16(64.0)	9 (36.0)	25(100)	2 (8.0)	23 (92.0)	25(100)
	P	X2=2.1 p>0.05			X2=0.6 p>0.05*
42	Gender
	Girl	15(60.0)	10 (40.0)	25 (100)	7 (28.0)	18 (72.0)	25 (100)
	Boy	12(54.5)	10 (45.5)	22 (100)	3 (13.6)	19 (86.4)	22(100)
	P	X2=0.50 p>0.05			X2=1.4 p>0.05
	Level of parental education**
	Middle school or less	6 (40.0)	9 (60.0)	15(100)	3(20.0)	12(80.0)	15(100)
	High School	8 (61.5)	5 (38.5)	13(100)	4(30.8)	9(69.2)	13(100)
	University	13(68.4)	6 (31.6)	19(100)	3(15.8)	16(84.2)	19(100)
	P	X2=1.7 p>0.05 *			X2=2.5 p>0.05*
48	Gender
	Girl	19(73.1)	7 (26.9)	26 (100)	8 (30.8)	18 (69.2)	26 (100)
	Boy	13(46.4)	15(53.6)	28 (100)	3 (10.7)	25 (89.3)	28 (100)
	P	X2=0.50 p>0.05*			X2=3.3 p>0.05*
	Level of parental education**
	Middle school or less	3 (23.1)	10 (76.9)	13(100)	3(23.1)	10(76.9)	13(100)
	High School	8 (66.7)	4 (33.3)	12(100)	4(33.3)	8(66.7)	12(100)
	University	21 (72.4)	8 (27.6)	29(100)	4(13.8)	25(86.2)	29(100)
	P	X2=2.8 p>0.05*			X2=0.02 p>0.05 *

* Fisher’s Exact Test

**Combined analysis of “middle school or less” and “high school” educational levels

DD Developmental delay

Discussion

ECC has been recognized as a significant public health problem impacting not only the physical health but also growth and development, and the quality life of the children [2, 14–17]. ECC adversely affects the children’s daily routines by leading to pain-induced malnutrition and somnipathy whereas causes some mental development disorders, such as loss of self-confidence, social interaction difficulties and elevated anxiety [18]– [19]. Although the effects of ECC on growth, development, and quality of life have been previously investigated, this study aimed to offer a novel perspective based on the assumption that ECC may have other, less explored impacts.

Obtained study data manifested that ECC was not merely an oral health problem but a potential predisposing factor of psychosocial wellness of the children. The correlation between dental caries and mental development in children is a broad-spectrum topic including several physiological, psychological and socio-environmental parameters. Especially, untreated ECC may have large impacts on psychomotor and cognitive development of children. Impairment in masticatory functions, malnutrition and delayed verbal communication skills are among these effects. Bramantoro et al. [20] emphasized the necessity for comprehensive researches investigating how sECC influences the cognitive functions. Furthermore, they stated that additional studies are needed to examine the effects of ECC on oral dysfunctions, such as physical malocclusion, speech distortion, and disarticulation or poor language development.

A couple of studies have been conducted to examine the effects of dental caries and other oral pathologies on mental health or vice versa [21–24]. Previous studies illustrated that poor oral hygiene might result in anxiety and depression by negatively affecting the self-esteem and confidence and subsequent psychotropic medication may lead to xerostomia, worsening the oral health [22–24]. Low-grade chronic inflammation and oxidative stress associated with caries and periodontal diseases may trigger mechanisms of molecular mimicry, which in turn can cause autoimmune reactions [25].

In the present study, the ASQ^®-TR and ASQ^®-SE-TR screening instruments were utilized to examine the potential impacts of ECC and sECC on early childhood mental and social-emotional development.

These tool kits systemically screen children’s early motor, language, social and cognitive developments and help determining whether they have reached age-appropriate developmental levels [12]– [13]. It was found that the mean scores of children aged 36, 42, and 48 months exceeded the cut-off thresholds in all domains, and these results were consistent with those of multiple ASQ^®-based studies conducted in other countries [26–28]. In this study, analysis of ASQ^®-TR results revealed that mean scores of all participants for every domain in 36-, 42- and 48-month age groups fell behind the cutoff values. In their study carried out with Norwegian children, Stensen et al. [29] noted a mean ASQ^® score of 35.15 for 36-months-old children and 25.70 for 48-month-olds. Our mean scores of 45.1 for 36-months-old children and 43.2 for 48-month-olds were much higher than those of Stensen et al. [29] This result may be attributed to the fact that two-thirds of the study population consisted of children with caries experience, as well as to socioeconomic differences between Türkiye and Norway.

In the present study, for all participating 36-, 42-, and 48-months-old children, ASQ^®-TR developmental delay scores were obtained as 8.2%,17%, and 9.3% respectively whereas ASQ^®-SE-TR risk scores of 14.3%, 21.3%, and 20.4% were observed respectively. ASQ^®-TR screening test completed for 36-, 42-, and 48-months-old children with caries indicated risk scores of 17.2%, 21.4%, and 58.8%. Likewise, in ASQ^®-SE-TR screening test administered for assessing the emotional wellness of children, higher risks increasing with age were found among the caries-experienced ones. These age-dependent risks are thought to be associated with the increasing severity of untreated caries, which progresses over time. Indeed, untreated caries will eventually involve the dental pulp and cause pain and thus, may negatively affect the developmental skills. Since this was the first known study to evaluate ECC using the ASQ^® and ASQ^®-SE screening tools, no comparable or conflicting findings were available in the existing literature.

In addition to ASQ^® and ASQ^® -SE, there are several other screening tests assessing the impact of ECC on developmental and psychomotor skills of the children. In some Latin American countries, a number of studies have been conducted using two screening tools called as “Test de aprendizaje y Desarrollo Infantil-TADI” (Child learning and development test) and “Test de Desarrollo Psicomotor-TEPSI” (Psychomotor development test), which were invented for different age groups [30]– [31]. In their research carried-out with TEPSI among 3 years-old children, Nunez et al. [30] elucidated the correlation between severity of dental caries and early childhood development. Liang et al. [32] suggested that ECC caused psychomotor deficits in the preschool children. Data from both researches support the current study.

In the present study, ASQ^®-TR risk + developmental delay was measured as 80%, 60% and 76.9% respectively for 36,42 and 48 months-old children of graduates ≤ the middle school whereas ASQ^®-SE-TR scores of risk + developmental delay was observed as 26.7%, 20%, and 23.1% respectively for the same age groups. Previous research has similarly indicated that limited parental education and lower socioeconomic status may elevate developmental and social-emotional risks, which is consistent with the current study’s findings.

In their study assessing ASQ^®−3 as a developmental screening toolkit in 9-, 18-, and 24-months-old children, Agarwal et al. [33] remarked that environmental factors such as, low income and maternal education increased the risk scores in all age groups. Furthermore, it has been reported that poverty and its accompanying factors (maternal stress, malnutrition, overcrowded living conditions, low parental education) were closely associated with the structural brain changes, which consequently resulted in cognitive and academic challenges [34]– [35].

A local cohort study accomplished in Singapore revealed that low level of maternal education and socioeconomic status were significantly correlated with poor home literacy environment and child-centered literacy orientation. Furthermore, anthropometric data such as height and weight were not included in this study. Including such measures would have allowed for a broader analysis of general growth patterns in relation to ECC and developmental progress. Considering the importance of language skills on the future cognitive and academic achievements, early identification of possible developmental delays might simplify the preventive and intrusive measures [36]. Although the study was not primarily designed to correlate dmf-t scores with ASQ^® results, descriptive trends suggested that higher dmf-t values were associated with slightly lower developmental scores, especially in the sECC group. Further studies with correlation analyses are warranted.

Differences in the scores of ASQ^® and ASQ-SE by gender have been researched in several studies [33, 37]. Agarwal et al. [33] reported that boys had lower ASQ^®−3 development scores than the girls.

Although higher scores of ASQ^®-TR risk and development were obtained among the boys in all age groups in the present study, no statistically significant difference was found. Similarly, a Norwegian study also presented that boys had lower ASQ^®−3 developmental scores than the girls [37].

Being associated with the academic achievements at the later stages of life, behavioral development is an important dynamic in the early childhood [38]– [39]. A number of researches manifested that gender might cause social-emotional development disparities in early childhood [40]– [41]. Li et al. [42] evaluated the social-emotional developments of 18–30-months-old-children in the rural China using ASQ^® screening tool and observed that boys fell behind the girls in social-emotional development. Another study completed in Iceland presented that 6 years-old-girls outperformed the boys of the same age in the self-regulatory skills [40]. In contrast to previous research, higher risks of socio-emotional developmental concerns were observed among girls in the 42- and 48-month age groups based on the ASQ^®-SE-TR scale, which may be related to underlying sociocultural factors.

Findings of the present study showed that ASQ^®-TR and ASQ^®-SE-TR screening tool kits might be used to detect the development delays and social-emotional developmental risks in the children experiencing ECC. However, further studies are required to examine the effects of ECC on developmental progress and social-emotional development.

One limitation of this study is that the final sample size (n = 150) was slightly below the minimum required (n = 159) as determined by a priori power analysis using G*Power. This discrepancy was due to practical challenges in participant recruitment. Although this may have slightly affected the statistical power, the results still offer important initial insights into the relationship between early childhood caries and mental development.

Conclusion

Despite certain limitations, this study was thoughtfully designed and contributes valuable insight into the potential effects of ECC on child development using standardized screening tools. Acknowledging the potential effects of ECC not only on growth, development, and quality of life but also on social-emotional well-being, a timely and effective ECC management is very important. More efficient oral health programs and preventive strategies should be established to provide protection for developing children because ECC adversely affect both early childhood and future existence.

Abbreviations

ECC

Early Childhood Caries

sECC

Severe Early Childhood Caries

AAPD

American Academy of Pediatric Dentistry

CRP

Creactive Protein

ASQ^®

Ages & Stages Questionnaire^®.

ASQ^®-SE

Ages & Stages Questionnaire^® Social-Emotional.

ASQ^® SE-TR

Turkish adaptation of the Ages & Stages Questionnaire^® Social-Emotional.

DCU

Dental Chair Unit

WHO

World Health Organization

CPI

Community Periodontal Index

dmft

decayed missing and filled teeth

Authors’ contributions

Conceptualization: [S.S.D]; Methodology: [S.S.D., E.Y.D., Z.K., Ç.Ö., B.P.G.]; Formal analysis and investigation: [Ç.Ö, B.P.G., E.B.Y., Z.K.]; Writing - original draft preparation: [S. S.D., F.S., P.Ç.]; Writing - review and editing: [S.S.D., F.S., A.B.Ö.]; Funding acquisition: [Ç.Ö., B.P.G., M.B.]; Resources: [Ç.Ö., B.P.G., P.Ç., M.B.]; Supervision: [S. S. D., E.B.Y.]

Funding

No funding.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of the Medical University of Atatürk (Date: 29.11.2024/Session no: B.30.2.ATA.0.01.00, resolution #753).

Informed consent was obtained from the parents of all children included in the study.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.