Abstract
Introduction:
Dental caries is a biofilm-mediated, multifactorial disease of the dental hard tissues. Maternal psychosocial and behavioral factors can affect a child’s risk for many chronic childhood conditions including dental caries. We examined the relationship between maternal psychological wellbeing during and after pregnancy on caries experience in 3-year-old offspring.
Methods:
Using data from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study (N=667), maternal psychological wellbeing including depressive symptoms [Edinburg Postnatal Depression scale (EPDS), anxiety symptoms [State Trait Anxiety Inventory (STAI)], and sleep quality were measured. Offspring dental caries experience was defined as having at least one decayed, missing, and filled teeth or surface (dmft ≥1 vs.0 /dmfs ≥1 vs. 0). We estimated associations between maternal psychological wellbeing in the pre- and post-natal periods with offspring dental caries experience using logistic regression models adjusted for several maternal and child demographic and socioeconomic factors.
Results:
The mean maternal age at delivery was 31 (SD: 5.1) years with ethnic distribution of 55% Chinese, 28% Malay, and 17% Indian; 8.6% of mothers had a prenatal EPDS score ≥15 indicating probable depression and 44% of the children had dmft ≥1. Children of mothers with high prenatal EPDS scores (≥15) had 1.57 times (95% CI: 0.85 – 2.93) the adjusted odds of dental caries experience as compared to children of mothers with prenatal EPDS score <15, although this association was not statistically significant. Moreover, children of mothers with consistently high/changing EPDS and STAI scores in the pre- and postnatal periods had adjusted odds of caries experience of 1.65 (95% CI: 1.01 – 2.72) and 1.24 (95% CI: 0.89 – 1.74), respectively when compared to children whose mothers had consistently low EPDS and STAI scores, though only EPDS association was statistically significant. Associations with poor sleep quality followed a similar direction, although not statistically significant.
Conclusion:
While the current findings did not consistently demonstrate statistically significant associations, they suggest a potential role of maternal psychological wellbeing during and after pregnancy on children’s oral health status.
Keywords: Dental Caries, Depression, Anxiety, Epidemiologic birth cohort, psychological wellbeing
Introduction
Dental caries is a biofilm-mediated, multifactorial disease of the teeth [1] and a significant global health concern [2]. Untreated caries causes pain, eating difficulties, infections, and a higher chance of developing new dental caries in both primary and permanent teeth which can have serious social and financial implications for families [3, 4]. A recent systematic review spanning 1960 to 2019 reported that 48% of preschool children had dental caries in their primary teeth globally [5]. In Singapore, 40% of preschool children were affected by caries, making it one of the most common chronic childhood diseases [6]. Etiology of dental caries is multifactorial comprising acquired (social, economic, lifestyle and educational), inherited (genetic variants) and local oral environmental factors [2, 7]. Further, maternal psychological wellbeing and behavioral factors affect a child’s risk for many chronic childhood conditions including dental caries [8, 9]. Mental health disorders are common in reproductive age women with approximately 25% of women affected [10]. Chronic caregiver stress postnatally predisposes to depression and anxiety symptoms in the caregiver [11] that likely increases the risk for dental caries in the dependent child [8, 9, 12–16] by way of suboptimal parenting and caretaking, neglect and less attention given to preventive oral healthcare. In addition to evidence indicating that parental psychosocial factors affect dental caries risk in the dependent child, evidence further suggest that mothers suffering from chronic stress are more likely to neglect their children’s health by way of poor feeding patterns [16–19] and poor child-rearing behaviors [9, 20–23]. Effects can begin in-utero although studies examining links between maternal emotional and psychological state during pregnancy and its impacts on caries development in the child have reported mixed findings [10, 24–27]. Infants born to depressed mothers face a heightened risk for insecure attachment, negative affect, and dysregulated attention and arousal [28]. These factors can adversely impact their behavioral and physical growth [10]. The objective of the current study was to examine associations among maternal 1) prenatal psychological wellbeing alone; 2) trajectories of psychological wellbeing in the pre-and postnatal periods and offspring dental caries experience at age 3 years old. We hypothesize that poor maternal psychological wellbeing will in the prenatal period alone and over time will be associated with higher caries experience among 3-year-old offspring. Examining trajectory of maternal psychological wellbeing on offspring caries experience represents a novel contribution of this study.
Materials and Methods
Study design and population
Growing Up in Singapore Towards healthy Outcomes (GUSTO) is a pregnancy cohort aimed at evaluating the role of exposures during early development and their impacts on metabolic compromise and altered body composition [29]. GUSTO recruited 1,341 pregnant women between June 2009 and October 2010 at 7–11 weeks of gestation from the National University Hospital (NUH) and KK Women’s and Children’s Hospital (KKH) in Singapore. Detailed interviews of the mothers were conducted at recruitment and at weeks 26–28 of gestation. In home follow-up for mother and offspring occurred at postnatal week 3, 3 months and every 3 months until age 15 months while clinic visits for offspring took place at 18, 24 and 36 months. Examination to determine offspring oral health status occurred at the 24- and 36- months clinic visits. This study protocol was approved by the Institutional Review Board of the National University of Singapore and KKH (DSRB_D/2009/00021, DSRB_D/2010/00021, DSRB_B/2014/00406, NUS-IRB-2024–312). The written informed consent was obtained for participation in this study.
Exposures
Pregnant women completed several well-established self-administered standardized questionnaires to assess their psychological wellbeing during pregnancy [gestational week (GW) 26], and at 3-, 12-, 24- and 36-months after birth [30]. Psychological wellbeing measures considered for this study were depression symptom indicators: Edinburgh Postnatal Depression Scale (EPDS), and Beck Depression Inventory-II (BDI); Anxiety/stress indicators: State Trait Anxiety Inventory (STAI), and sleep quality assessed using the Pittsburg Sleep Quality Index (PSQI).
Depression symptoms scales
The Edinburgh Postnatal Depression Scale (EPDS)
[31] is a self-reported scale used to screen for depression symptoms in the pre- and postnatal periods among pregnant and non-pregnant women. The 10-item EPDS assesses depression symptoms in the last 7-days with response options recorded on a Likert scale of 0–3 with total possible score range of 0–30. Higher scores indicate worse depression symptoms. We utilized an EPDS score ≥15 as an indicator of probable depression as in prior work [30]. The EPDS was administered at GW 26 and at 3-, and 24-months after birth.
The Beck Depression Inventory (BDI)
is a widely used depression symptom assessment [32]. The GUSTO cohort administered the 1996 revised version of the 21-item BDI-II which places more emphasis on the psychological and somatic manifestations of major depressive episodes lasting for ≥2 weeks [33]. Each item is rated on a Likert scale of 0 to 3 with a total possible score range of 0 to 63 [32]. Higher scores indicate worse depression symptoms. We used a score ≥20 as the threshold for moderate/severe depression [34]. The BDI-II was administered at GW 26 and at 3-, 12-, 24- and 36-months after birth.
Anxiety/stress symptoms scales
The State-Trait Anxiety Inventory (STAI)
is a 40-item assessment designed to evaluate anxiety symptoms [35]. It distinguishes between two types of anxiety: state anxiety, which captures immediate feelings of anxiety experienced in the present moment, and trait anxiety, which reflects a person’s general disposition towards anxiety over time [36]. In the current study we considered separately, state (STAI-S) and trait (STAI-T) anxiety sub scores and the combined STAI-total anxiety score. The STAI questionnaire includes 20 questions for the STAI-S and 20 questions for the STAI-T. Each question is rated on a 4-point Likert scale. The score range for both the STAI-S and STAI-T subscales is from 20 to 80 and 40 to 160 for the STAI-total score [34]. A higher score indicates a higher level of anxiety symptoms [37]. We utilized the 75th percentile of the total participants’ scores as the threshold [30] to indicate presence of anxiety symptoms. The STAI was administered at GW26 and at 3-, 12-, 24- and 36-months after birth.
The Pittsburgh Sleep Quality Index (PSQI)
is a self-report questionnaire designed to evaluate sleep quality during the past month. It is comprised of 19-items that contribute to seven component scores of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction [38]. The global score, ranging from 0 to 21, is derived by summing the component scores [30]. A global PSQI score >5 indicates poor sleep quality, while a score of ≤5 indicates good sleep quality [38]. The PSQI questionnaire was administered at GW 26 and at 3-, 6-, 12-, 24-, 36- months after birth.
Outcome
Oral examinations at the 2- and 3-year clinic visits were done at KKH and NUH by trained and calibrated dentists, with a single examiner conducting the examinations at the year 2 visit and 3 examiners at the year 3 visit. Children were asked not to eat, drink or brush their teeth for a least one hour prior to the oral examination. Examinations were performed in the knee-to-knee position, and teeth were assessed by visual inspection using plane surface mouth mirrors, and by tactile inspection when necessary, using blunt World Health Organization probes to avoid damage to sound enamel [39, 40]. For uncooperative children, oral examination was paused, allowing them to see interactions with other cooperative children (modeling). If the child remained resistant, they went through other GUSTO measurements before coming back on the same day or another to complete oral examination.
Dental caries was determined using the International Caries Detection and Assessment System (ICDAS) [1] and World Health Organization (WHO) [41] criteria at the tooth and tooth surface levels among 2 and 3-year old children. However, due to a high proportion of missingness (33.6%) for caries experience at age 2 years, this study only looked at caries at 3-years old to preserve sample size. ICDAS criteria codes 2–6 were used for evaluating the presence of caries. Children’s teeth were not dried during oral examination which made the use of ICDAS code-1 difficult [40].
Calibration sessions were conducted on a separate sample of 3–4 year old children (n=34) rather than children enrolled in the GUSTO study to ensure that the examiners were properly calibrated for consistency and reliability before applying it to the study group. Each child in the calibration sample was examined by both the gold standard examiner and the examiners being calibrated on site. Each examiner re-examined the same set of children after a 2-week interval to minimize recall bias by examiners and to ensure that natural changes in the children’s dental condition could not have occurred. The inter-examiner and intra-examiner reliability scores were respectively 0.76 and 0.95 for ICDAS codes 1–2 and 1.00 and 1.00 for ICDAS codes 3–6.
For this study, we considered caries experience as having ≥1 decayed, missing and filled teeth or tooth surfaces based on the ICDAS and WHO criteria and the reference group as having no caries. We used both ICDAS and WHO criteria because both caries assessment methods were available in the GUSTO cohort. Further, caries assessment using the ICDAS method includes incipient lesions which provides more statistical power to detect difference if present as opposed to the WHO method which only includes cavitated carious lesions. ICDAS also allow for the study of the spectrum of dental caries which includes incipient lesions. Utilizing both caries assessment methods ensure robustness of our data analysis and will allows us to compare the findings from the two caries assessment methods.
Covariates
Covariates considered for this study included: maternal age at delivery (years); maternal ethnicity (Chinese, Malay, Indian); maternal education (≤secondary, >secondary but <University, University); maternal smoking during pregnancy or exposure to secondhand smoke (SHS) (smoker and SHS exposed, smoker or SHS exposed, non-smoker)(see Supplementary material); gestational diabetes at GW 26 (yes v. no) based on fasting plasma glucose ≥7.0 mmol/L or 2-hour plasma glucose level ≥7.8 mmol/L; child sex (male or female), child weight at birth (grams), preterm birth status (<37 weeks v. ≥37 weeks), child tooth brushing frequency (<1 daily, once, and >1 daily), plaque index score (0 to 3) based on the modified Silness-Löe plaque index [42] (see Supplementary material), mode of delivery (spontaneous vaginal, assisted/cesarean section), and duration of exclusive breastfeeding (<1 month v. ≥1 month).
Statistical Analysis
We summarized continuous variables using means and standard deviations and used numbers and percentages to summarize binary and categorical variables and evaluated differences in continuous and categorical variables using analysis of variance and chi square tests respectively. To independently evaluate maternal depression symptom and anxiety/stress related symptom scores during pregnancy on offspring tooth [decayed, missing and filled teeth (dmft)] and tooth surface (dmfs) caries experience based on ICDAS and separately the WHO criteria at age 3 years, we used a logistic regression that estimated odds ratios and 95% CI.
To independently evaluate changing maternal psychological wellbeing i.e., depression symptoms and anxiety/stress related symptoms across the prenatal and postnatal periods, we created 3 groups of psychological symptom states overtime for each of the psychological wellbeing scales. Group 1 (reference) comprised mothers whose psychological wellbeing scores were consistently low at each time point the scales were administered. For instance, a woman belonging to this group will have BDI score <20 at each time point or an EPDS score of <15 at each time point. Group 2 comprised of mothers whose psychological wellbeing scores were consistently elevated at each time point the individual scales were administered. A woman in this group will have a BDI score ≥20 at each time point or an EPDS score ≥15 at each time point. Group 3 comprised of mothers whose psychological wellbeing scores were not consistently high or low over time. Due to the few observations in the consistently high psychological wellbeing symptoms group (n=9 for BDI, n=28 for EPDS, n=75 for STAI), we merged them with the fluctuating psychological wellbeing symptom scores group to obtain statistically robust estimates. PSQI had adequate observations in the consistently high score group (n=147), so we retained its classification as consistently low, changing, and consistently high. We proceeded to use logistic regression to model the associations between high/changing psychological wellbeing scores as compared to consistently low psychological wellbeing symptoms scores groups on caries experience in the offspring at age 3. Exploratory data analysis and descriptive analysis were conducted using SAS (SAS Institute Cary, NC), while regression modeling was done in R (R version 4.3.2). Reporting for this study adhered to the STROBE guidelines for observational studies.
Results
A total of n=667 with non-missing data on exposure, outcome and covariates were included in the current study. There were no meaningful differences in covariate distribution between those included and excluded from our study (Supplementary Table 1).
Summary of sociodemographic factors
Slightly less than half of the children were girls (49%), most were born at term (93%) and 94% brushed their teeth at least once a day at age 3 years. The average maternal age at delivery was 31 (SD: 5.1) years and 33% completed university education, with ethnic distribution as follows: 55% Chinese, 28% Malay, and 17% Indian. The overall mean (SD) for BDI, EPDS, STAI and PSQI at GW 26 were 8.55 (6.17), 7.69 (4.40), 71.2 (17.9), 5.53 (2.92) respectively. The mean psychological wellbeing scores for mothers of female as compared to male children were respectively: BDI (8.72 vs. 8.39), STAI (71.9 vs. 70.5) and PSQI (5.58 vs. 5.49). The scores for mothers of children born preterm as compared to mothers of children born at term were: BDI (8.66 vs. 8.54), EPDS (8.93 vs. 7.59), total STAI score (72.7 vs. 71.1) and PSQI (6.12 vs. 5.50). Psychological wellbeing symptoms scores also differed according to mother’s ethnicity whereby mothers of Indian ethnicity scored more on the BDI-II, EPDS, STAI and PSQI than Chinese and Malay mothers (Table 1).
Table 1.
Summary of sociodemographic factors overall and according to maternal psychological wellbeing symptoms score
| Overall N (%) |
BDI-II Mean (SD) |
EPDS Mean (SD) |
STAI (total) Mean (SD) |
PSQI Mean (SD) |
|
|---|---|---|---|---|---|
|
| |||||
| Overall | 667 (100%) | 8.55 (6.17) | 7.69 (4.40) | 71.2 (17.9) | 5.53 (2.92 |
|
| |||||
| Infant sex | |||||
| Female | 325 (48.7%) | 8.72 (6.61) | 7.62 (4.47) | 71.9 (18.9) | 5.58 (3.15) |
| Male | 342 (51.3%) | 8.39 (5.72) | 7.75 (4.34) | 70.5 (16.9) | 5.49 (2.69) |
| Preterm babies | |||||
| GA < 37 weeks | 47 (7.0%) * | 8.66 (6.73) | 8.93 (4.78) | 72.7 (19.3) | 6.12 (3.30) |
| GA ≥ 37 weeks | 620 (93.0%) * | 8.54 (6.13) | 7.59 (4.36) | 71.1 (17.8) | 5.50 (2.89) |
| Tooth brushing frequency | |||||
| <1 daily | 37 (5.6%) * | 7.19 (4.27) | 7.69 (4.03) | 73.8 (16.4) | 4.89 (3.00) |
| Once daily | 282 (42.4%) * | 8.23 (5.46) | 7.40 (4.25) | 69.8 (17.7) | 5.24 (2.84) |
| >1 daily | 346 (52.0%) * | 8.97 (6.85) | 7.89 (4.56) | 72.0 (18.3) | 5.80 (2.94) |
| Missing | 2 | ||||
| Plaque index score | |||||
| 0-<1 | 553 (82.9%) * | 8.60 (6.28) | 7.73 (4.36) | 71.5 (17.9) | 5.60 (3.00) |
| 1--<2 | 65 (9.7%) * | 8.30 (5.78) | 7.17 (4.50) | 69.4 (18.7) | 4.84 (2.41) |
| 2-<3 | 32 (4.8%) * | 9.59 (5.84) | 8.34 (5.06) | 72.7 (18.8) | 6.09 (2.71) |
| 3 | 17 (2.5%) * | 5.75 (3.57) | 7.00 (4.07) | 65.4 (14.6) | 5.08 (2.27) |
| Mother’s ethnicity | |||||
| Chinese | 365 (54.7%) * | 7.66 (5.51) * | 7.10 (4.28) * | 69.9 (17.7) | 5.19 (2.79) |
| Malay | 186 (27.9%) * | 10.1 (6.48) * | 8.31 (4.36) * | 73.9 (17.2) | 5.85 (2.90) |
| Indian | 115 (17.2%) * | 8.96 (7.15) * | 8.59 (4.61) * | 71.2 (19.3) | 6.01 (3.22) |
| Missing | 1 | ||||
| Age at delivery | |||||
| <30 years | 296 (44.4%) * | 9.49 (6.58) * | 8.13 (4.40) * | 73.2 (18.4) * | 5.40 (2.75) |
| ≥30 years | 371 (55.6%) * | 7.81 (5.72) * | 7.34 (4.38) * | 69.6 (17.4) * | 5.64 (3.05) |
| Education level | |||||
| ≤Secondary | 215 (32.5%) | 9.55 (7.19) * | 8.51 (4.57) * | 76.5 (17.8) * | 5.85 (2.93) |
| Secondary -<University | 226 (34.1%) | 8.72 (5.95) * | 7.70 (4.23) * | 70.6 (17.4) * | 5.63 (2.84) |
| ≥University | 221 (33.4%) | 7.45 (5.04) * | 6.89 (4.25) * | 66.8 (17.3) * | 5.28 (2.96) |
| Missing | 5 | ||||
| Exclusive breastfeeding duration | |||||
| <1 month | 517 (80.4%) * | 8.74 (6.32) * | 7.91 (4.44) * | 72.1 (18.2) * | 5.71 (2.94) * |
| ≥1 month | 126 (19.6%) * | 7.55 (5.05) * | 6.50 (4.04) * | 66.1 (15.8) * | 4.95 (2.83) * |
| Missing | 24 | ||||
| Mode of delivery | |||||
| Spontaneous | 429 (64.3%) * | 8.47 (6.18) | 7.51 (4.43) | 70.3 (17.9) | 5.57 (3.03) |
| Assisted/Cesarean section | 238 (35.7%) * | 8.70 (6.15) | 8.01 (4.35) | 72.7 (18.0) | 5.47 (2.71) |
| Gestational diabetes at GW26 | |||||
| No | 533 (83.2%) * | 8.57 (6.14) | 7.67 (4.43) | 71.6 (17.9) | 5.48 (2.86) |
| Yes | 108 (16.8%) * | 7.99 (6.15) | 7.28 (4.25) | 67.9 (17.5) | 5.68 (3.21) |
| Missing | 26 | ||||
| Prenatal smoking | |||||
| Smoker and SHS exposed | 14 (2.1%) * | 13.8 (7.43) * | 11.7 (3.93) * | 86.9 (11.5) * | 6.80 (2.57) |
| Smoker or SHS exposed | 233 (35.3%) * | 9.98 (6.78) * | 8.53 (4.40) * | 74.8 (17.6) * | 5.79 (2.98) |
| Non-smoker | 413 (62.6%) * | 7.58 (5.51) * | 7.08 (4.28) * | 68.6 (17.7) * | 5.36 (2.88) |
| Missing | 7 | ||||
BDI-II: The Beck Depression Inventory; EPDS: The Edinburgh Postnatal Depression Scale; STAI: The State-Trait Anxiety Inventory; PSQI: The Pittsburgh Sleep Quality Index; SHS: Secondhand Smoke; GA: Gestational Age.
p ≤0.05, p-values under "Overall" column refer to comparisons of categorical variables using Pearson’s chi-square test. P-values for continuous outcomes were calculated to compare mean scores across levels of each categorical variable: t-tests were used for binary variables (e.g., infant sex), and one-way ANOVA was used for variables with more than two categories (e.g., Tooth brushing frequency).
When we cross-classified sociodemographic factors according to trajectory of psychological wellbeing scores over time, we found that the proportion of Malay and Indian mothers with consistently high/changing psychological wellbeing scores (BDI, EPDS, STAI) were more than the corresponding proportions in the consistently low psychological wellbeing scores group as compared to the proportions for Chinese mothers. Likewise, there was a larger proportion of younger mothers (<30 years at delivery) in the consistently high/changing psychological wellbeing score group (BDI, EPDS, STAI) than in the consistently low scores group. This was also the case for mothers with assisted delivery/caesarean section, and among mothers who reported smoking/exposed to ETS (Supplementary Table 2).
Table 2 summarizes the psychological wellbeing symptom scores at GW 26 and offspring caries experience at age 3 years. The majority (82%) had BDI scores of 0 to 13 (no depression symptoms), 12% had a score indicating mild depression symptoms and 1% had score (29–63) indicating severe depression symptoms. On the EPDS scale, 8.6% of mothers exceeded the threshold of ≥15 indicating probable depression. About a quarter of mothers scored high on the STAI scale, for STAI-total (25%), STAI-S (27%) and STAI-T (26%) subscales. Sleep quality was poor (PSQI >5) among 44% of mothers. Caries experience differed based on criteria used for determining caries. Specifically, 21% had ≥1 teeth/surfaces affected based on the WHO criteria while 44% had ≥1 teeth/surfaces affected based on the ICDAS criteria.
Table 2.
Distribution of prenatal maternal psychological wellbeing symptoms score and offspring dental caries status at age 3
| Overall (N=667) | |
|---|---|
|
| |
| BDI | |
| minimal depression (0–13) | 524 (82.1%) * |
| mild depression (14–19) | 77 (12.1%) * |
| moderate depression (20–28) | 31 (4.8%) * |
| severe depression (29–63) | 6 (1.0%) * |
| Missing | 29 |
| EPDS | |
| Low depression (<15) | 586 (91.4%) * |
| Probable depression (≥15) | 55 (8.6%) * |
| Missing | 26 |
| STAI S-Anxiety | |
| Low anxiety (<41) | 466 (72.7%) * |
| Probable anxiety (≥41) | 175 (27.3%) * |
| Missing | 26 |
| STAI T-Anxiety | |
| Low anxiety (<43) | 470 (73.7%) * |
| Probable anxiety (≥43) | 167 (26.3%) * |
| Missing | 30 |
| STAI Total | |
| Low anxiety (<84) | 478 (74.5%) * |
| Probable anxiety (≥84) | 164 (25.5%) * |
| Missing | 25 |
| PSQI | |
| Good sleep (≤5) | 241 (55.7%) * |
| Poor sleep (>5) | 192 (44.3%) * |
| Missing | 234 |
| ICDAS-dmfs | |
| 0 surfaces | 373 (55.9%) * |
| ≥1 surface | 294 (44.1%) * |
| ICDAS-dmft | |
| 0 tooth | 373 (55.9%) * |
| ≥1 teeth | 294 (44.1%) * |
| WHO-dmfs | |
| 0 surfaces | 525 (78.7%) * |
| ≥1 surface | 142 (21.3%) * |
| WHO-dmft | |
| 0 tooth | 525 (78.7%) * |
| ≥1 teeth | 142 (21.3%) * |
BDI-II: The Beck Depression Inventory; EPDS: The Edinburgh Postnatal Depression Scale; STAI: The State-Trait Anxiety Inventory; PSQI: The Pittsburgh Sleep Quality Index; ICDAS: International Caries Detection and Assessment System; WHO: World Health Organization; dmfs: Decay, Missing, Filled Surfaces; dmft: Decayed, Missing, and Filled Teeth; Probable STAI corresponds to the 75th percentile score for each of the STAI scores.
statistically significant at p≤0.05, p-values are calculated using the Pearson’s chi-square test for categorical variables.
Association between prenatal depression and anxiety/stress symptoms score and offspring caries experience at age 3.
High scores on the EPDS and STAI (total, state, trait) were associated with statistically non-significant unadjusted and adjusted odds of ICDAS caries experience at age 3 years. Specifically, the unadjusted and adjusted odds ratio for caries experience of children whose mothers had prenatal EPDS ≥15 compared to children of mothers with EPDS score <15 was respectively OR: 1.61, 95% CI: 0.93–2.83 and OR: 1.57, 95% CI: 0.85, 2.93. Higher total STAI score (≥84 vs. <84) was associated with an unadjusted odds of caries experience at age 3 of 1.42, 95% CI: 1.00, 2.03 that lost statistical significance upon adjustment for covariates, OR: 1.26, 95% CI: 0.85, 1.87 (Table 3). The findings were qualitatively similar when caries experience was characterized using the WHO criteria, but the associations were of smaller magnitude and were also not statistically significant (Supplementary Table 3). Poor sleep quality in the prenatal period was associated with a statistically non-significant adjusted odds of offspring caries experience at age 3 years, OR: 1.16, 95% CI: 0.76, 1.77.
Table 3.
Association between Prenatal Maternal Psychological Wellbeing symptom scores and ICDAS dental caries experience among 3-year-old offspring
| Unadjusted |
Adjusted |
|||||||
|---|---|---|---|---|---|---|---|---|
| OR | lower CI | upper CI | OR | lower CI | upper CI | |||
|
| ||||||||
| BDI | No/mild | Ref. | Ref. | |||||
| moderate/severe | 1.09 | 0.55 | 2.11 | 1.02 | 0.49 | 2.12 | ||
| EPDS | Low | Ref. | Ref. | |||||
| Probable | 1.61 | 0.93 | 2.83 | 1.57 | 0.85 | 2.93 | ||
| STAI-S | Low anxiety | Ref. | Ref. | |||||
| Probable anxiety | 1.33 | 0.94 | 1.89 | 1.15 | 0.79 | 1.69 | ||
| STAI-T | Low anxiety | Ref. | Ref. | |||||
| Probable anxiety | 1.23 | 0.86 | 1.75 | 1.07 | 0.72 | 1.58 | ||
| STAI-total | Low anxiety | Ref. | Ref. | |||||
| Probable anxiety | 1.42 | 1.00 | 2.03 | 1.26 | 0.85 | 1.87 | ||
| PSQI | Good sleep | Ref. | Ref. | |||||
| Poor sleep | 1.02 | 0.69 | 1.50 | 1.16 | 0.76 | 1.77 | ||
Adjusted for child’s sex, preterm status, frequency of child’s teeth brushing, child’s plaque index score, child’s weight, mother’s ethnicity, mother’s age, mother’s highest education level, duration of full breastfeeding, delivery mode, gestational diabetes, and self-reported smoker or exposure to secondhand smoke. ICDAS- International caries detection and assessment system. At a threshold of 5%, no associations were statistically significant except for the unadjusted STAI Total.
Association between trajectory of pre- and post-natal depression and anxiety/stress symptoms score and offspring caries experience at age 3.
Like the associations reported for poor psychological wellbeing symptom scores during pregnancy, we found children whose mothers had consistently high/changing EPDS and STAI scores over the pre- and postnatal periods had poorer dental caries experience at age 3. For instance, when compared to children of mothers with low EPDS score, children whose mothers had high/changing EPDS score over follow-up had unadjusted OR (95% CI) =1.68 (1.06, 2.66) of caries experience at age 3. The association persisted upon covariate adjustment, 1.65, 95% CI: 1.01, 2.72, retaining its statistical significance. The adjusted OR (95% CI) for STAI-total of 1.24, 95% CI: 0.89, 1.74 was not statistically significant (Table 4). In contrast to changing sleep quality score between the pre- and postnatal periods that was associated with statistically non-significant odds of caries experience, children of women with consistently poor sleep quality (i.e., high score on PSQI) had statistically non-significant unadjusted and adjusted odds of caries experience 1.19, 95% CI: 0.79, 1.79 and 1.30, 95% CI: 0.82, 2.06 respectively (Table 4). The corresponding estimates using the WHO criteria are presented in Supplementary Table 4.
Table 4.
Association between Prenatal and Postnatal Maternal Psychological wellbeing symptom score and ICDAS offspring caries experience at age 3
| Unadjusted |
Adjusted |
||||||||
|---|---|---|---|---|---|---|---|---|---|
| N | OR | lower CI | upper CI | OR | lower CI | upper CI | |||
|
| |||||||||
| BDI | Low | 575 | Ref. | Ref. | |||||
| High/Changing | 92 | 1.25 | 0.81 | 1.95 | 1.28 | 0.80 | 2.07 | ||
| EPDS | Low | 582 | Ref. | Ref. | |||||
| High/Changing | 85 | 1.68 | 1.06 | 2.66 | 1.65 | 1.01 | 2.72 | ||
| STAI-S | Low | 349 | Ref. | Ref. | |||||
| High/Changing | 318 | 1.18 | 0.87 | 1.61 | 1.07 | 0.77 | 1.49 | ||
| STAI-T | Low | 371 | Ref. | Ref. | |||||
| High/Changing | 296 | 1.33 | 0.98 | 1.81 | 1.13 | 0.80 | 1.58 | ||
| STAI-total | Low | 378 | Ref. | Ref. | |||||
| High/Changing | 289 | 1.40 | 1.03 | 1.91 | 1.24 | 0.89 | 1.74 | ||
| PSQI | Low | 251 | Ref. | Ref. | |||||
| Changing | 269 | 0.86 | 0.61 | 1.22 | 0.96 | 0.65 | 1.41 | ||
| High | 147 | 1.19 | 0.79 | 1.79 | 1.30 | 0.82 | 2.06 | ||
Adjusted for child’s sex, preterm status, frequency of child’s teeth brushing, child’s plaque index score, child’s weight, mother’s ethnicity, mother’s age, mother’s highest education level, duration of full breastfeeding, delivery mode, gestational diabetes, and self-reported smoker or exposure to secondhand smoke. ICDAS- International Caries detection and assessment system. At a threshold of 5%, no associations were statistically significant except for the unadjusted and adjusted EPDS and the unadjusted STAI Total.
Discussion
Findings from the current study aimed at investigating associations among maternal psychological wellbeing in the prenatal and postnatal periods on offspring caries experience found consistently high/changing EPDS depression symptom score to be statistically significantly associated with worse offspring caries experience at age 3.
In our study, we used both the ICDAS and WHO criteria to assess dental caries. The main difference between these two caries assessment methods is that the WHO method only accounts for cavitated carious lesions while the ICDAS method includes incipient carious lesions [43, 44]. Although GUSTO did not collect exact ICDAS scores, ICDAS scores of ≥3 was recorded as non-cavitated and cavitated carious lesions to simplify the assessment. Because ICDAS captures non-cavitated lesions, it provides more statistical power to detect associations if present and the findings of our measures of associations of greater magnitude for the ICDAS as compared to the WHO method confirm this. Focusing only on the WHO criteria limits our ability to identify the impacts of maternal psychological wellbeing on the full spectrum of dental caries. Assessing early lesions as with the ICDAS in this and other studies [41, 45] is advantageous because it can help identify at-risk children before the lesions progress to more severe stages.
Our findings are consistent with prior research in Quebec that found significant associations between maternal mental health disorders before and during pregnancy and offspring dental caries hospitalization [24]. Our study in Singapore focused on maternal psychological wellbeing symptoms during and after pregnancy, while the Quebec study focused on maternal mental health disorders before and during pregnancy. Despite differences in methodology, both studies consistently demonstrate poorer caries outcomes among offspring of mothers with poorer psychological wellbeing symptoms scores. Further, emerging evidence indicate stability of maternal mental health status from preconception to the postpartum period [46] underscoring the far-reaching effects of poor maternal mental health on offspring dental health.
The associations we reported for depression symptom scores for the EPDS than the BDI-II depression symptoms scale were divergent. BDI-II and EPDS are two widely used assessments for depressive symptoms. However, they have different intended populations and focus on specific depressive symptoms, which can lead to inconsistent results when comparing the two scales, despite both measuring depression symptoms. The BDI was designed to assess depression symptoms in adults, and it is not specifically designed for pregnant women. The scale includes questions on appetite and sleep patterns that can occur both during and after pregnancy but are not necessarily indicative of depression [47]. The EPDS was developed specifically to minimize item response bias related to the state of being pregnant and the postpartum period so that it may more precisely assess depressive symptoms around pregnancy. This may in part explain the stronger observed findings using the EPDS in the current study population. Another possible explanation could be that the EPDS includes an anxiety subscale (items 3,4, and 5) [48], and it may well be that the women with high/fluctuating EPDS scores over time could have high levels of anxiety so that the results mirror those of high/fluctuating STAI scores. Indeed, it has been suggested that high maternal anxiety may result is dental phobic anxiety or uneasiness, with resultant elevated gingival index in children [49].
Previous studies have provided a comprehensive global perspective on the relationship between maternal psychological wellbeing and childhood dental outcomes. In Brazil, Costa et al., found that maternal depression and anxiety correlated with poorer oral health-related quality of life in children [26], while a study in Germany identified various maternal psychopathological symptoms associated with early childhood caries with socioeconomic status playing a significant role [50]. Auger et al., study in Canada demonstrated that maternal mental disorders before or during pregnancy increase the risk of hospitalization for childhood caries [24]. Our study conducted in a Singaporean population adds to the body of literature by examining a population not represented in prior studies. Furthermore, the relationship between maternal mental health disorders and increased risk of childhood caries appears robust across geographical boundaries and cultural differences.
The concept that prenatal exposures affect offspring oral health is not new. A prospective cohort study previously highlighted that prenatal exposure to maternal smoking was associated with poor caries outcomes in the offspring [51] through earlier tooth eruption times and greater time in the oral cavity for caries to occur[52–54]. Hypothesized mechanisms by which poor psychological wellbeing during pregnancy negatively impacts offspring caries experience pertains to disruption in the tooth formation process which begins in-utero resulting in poorly mineralized teeth with greater caries susceptibility after eruption [24, 55]. While plausible, the current study is not equipped to test this hypothesis. Likewise, poor psychological wellbeing in the postnatal period likely results in maternal neglect of self-care, including oral hygiene and nutrition and a lower prioritization of dental care [56]. Consequently, poor maternal nutritional and oral hygiene habits can directly influence their children’s nutritional habits leading to a greater risk of dental caries. Although we found no significant mediation by child’s sugar intake.
Study Strengths
A major strength of this study is the longitudinal design. Indeed, maternal psychological wellbeing was assessed during pregnancy and in the postnatal period before caries occurrence in the child. Therefore, our findings are unlikely to be biased by maternal knowledge of the condition the children developed. To our knowledge, this is the first time this association has been reported in a predominately Asian population using different validated assessments of psychological wellbeing which further enhances the robustness of our findings. Another strength of this study is the exploration of changes in maternal psychological wellbeing over time and its impact on offspring caries experience.
Study Limitations
Some of the current study’s limitations include the small study sample, which likely produced statistically imprecise estimates. As findings may not be generalizable to other population groups, future studies should consider a larger and more diverse study sample. Another limitation is that psychological wellbeing symptoms scores based on validated questionnaires do not provide an indication of the chronicity of these conditions. We attempted to account for chronicity by looking at symptom scores over time and the associations with worse oral health in the offspring persisted. Unmeasured confounding may also have played a role in the observed associations. Factors such as parental oral health behaviors, and genetic predisposition [57] represent potential confounders that we did not adjust for due to a lack of data on these variables. This study considered caries experience as opposed to active carious lesions. So, if a carious lesion was present at 24 months and became inactive perhaps via restoration, they are still captured at 36 months as having experienced caries. As our dataset only included dmft and dmfs counts without detailed ICDAS scores, this prevented us from measuring the severity of disease and exploring associations with maternal psychological wellbeing.
Conclusions
This study adds valuable insights into the role of maternal psychological wellbeing indicators on childhood tooth decay. Additional research with larger and more diverse samples is necessary to definitively establish this association.
Supplementary Material
Acknowledgments
The authors thank the participating families whose generous donation of time made this study possible.
Funding Sources
GUSTO is supported by the Singapore National Research Foundation under its Translational and Clinical Research (TCR) Flagship Program and administered by the Singapore Ministry of Health’s National Medical Research Council (NMRC), Singapore (NMRC/TCR/004- NUS/2008; NMRC/TCR/012-NUHS/2014). Additional funding was provided by the Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR), Singapore.
During the preparation of this manuscript, AAA was supported by National Institute of Environmental Health Sciences (NIEHS), 5K12ES033594. The funding source had no role in the study design, collection, analysis, or interpretation of the data, manuscript writing, or in the decision to submit the manuscript for publication.
Footnotes
Conflicts of Interest
SYC is part of an academic consortium that report grants from Société Des Produits Nestlé S.A. and are co-inventors on patent filings by Nestlé S.A. SYC has received reimbursement and honoraria into her research funds from Nestlé Nutrition Institute and EGOI (Experts Group on Inositols) for speaking at conferences. The remaining authors report no conflicts of interest.
Statement of Ethics
This study was performed in accordance with the Declaration of Helsinki. This human study was approved by Institutional Review Board of the National University of Singapore and KK Women’s and Children’s Hospital - approval: DSRB_D/2009/00021, DSRB_D/2010/00021, DSRB_B/2014/00406, NUS-IRB-2024–312. All parents, guardians or next of kin provided written informed consent for the minors to participate in this study. All adult participants provided written informed consent to participate in this study.
Data Availability Statement
The data that support the findings of this study are not publicly available because the GUSTO cohort requires an approved study proposal before data release but are available from the corresponding author [AAA] upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are not publicly available because the GUSTO cohort requires an approved study proposal before data release but are available from the corresponding author [AAA] upon reasonable request.