الفهرس 
Introduction and Aim of the present studyOnly 14 pages are availabe for public view
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Abstract
Dental caries is the most common chronic disease of childhood, it is five times more common than asthma and seven times more common than hay fever. At the age of five, about 40% of children have ECC. Left untreated, carious lesions can result in costly treatment, growth and developmental disruption, pain, and serious infections. The prevalence of ECC, in Egypt, has a wide range (8-60%) and not only varied among different research but also from different governorates.
Dental caries is a multifactorial complex disease. The etiology of dental caries could be attributed to the infant feeding pattern early transmission of Mutans streptococci (MS), frequency of carbohydrate consumption and poor oral hygiene.
High cortisol level has been reported to be associated with higher susceptibility to dental caries. chronic stress reduces salivary flow rates. Corticosteroids induces atrophic changes in the major salivary glands, which can affect the amount of saliva (quantity) and its composition (quality) that can lead to the increased adherence and production of a cariogenic biofilm on the tooth surfaces and increase risk of caries.
Stress caused by environmental factors results in increased cortisol level as seen in children who live in poverty or in poor economic conditions, who are born to single mothers, whose parents have low educational level, especially those of illiterate mothers. Other environmental risk factors such as parent’s educational level, parents smoking and mother’s working status may also elevate cortisol level.
The prevalence of childhood stress has been shown to be high, with psychosocial stressors in the family life, kindergarten and school environment as the most frequently reported stressors in the child’s daily life.
In mobile phone users, there is a significant increase in all salivary oxidative stress indices. In addition, mobile phone users have decreased salivary flow, total protein, albumin and amylase activity. These observations lead to the assumption that the use of mobile phones may cause oxidative stress and modify salivary function which could promote the development of caries.
Because of scarcity of literature on the relationship between environmental stress factors and salivary cortisol level in children with dental caries in Egypt, the current study was designed to assess this relation.
The aim of the current study was to measure the salivary cortisol level as an indicator for environmental stress factors in children with dental caries in Alexandria. The specific objectives were to identify environmental stressors in the child’s everyday life in relation to dental caries in children, to measure the salivary cortisol level as a stress biomarker in relation to childhood caries and to find the relation between identified environmental stress factors and salivary cortisol level in children with dental caries. To achieve this aim, a case-control study was conducted in preschool nurseries in Alexandria and laboratories of the Department of Clinical Pathology, Faculty of Medicine, Alexandria University, Egypt.
The study included 80 children aged from 4 to less than 6 years. Cases were 40 children with caries as having at least one carious lesion (case group). Control group included 40 children with no history of/and current diagnosis of dental caries. Only one child will be chosen from each family. Exclusion criteria were children with systemic diseases or special health care needs, children taking medications that interfere with measures of salivary cortisol
Data was collected from parents or caregivers of the children enrolled in the present study using a pre-structured, pre-coded, interviewing questionnaire that included the socio-demographic data, potential environmental risk factors, Modified Pediatric Epworth Sleepiness Scale, potential socio-environmental stressors in the child’s everyday life, medical history and dental history. Clinical examination included caries experience (dmft index) and Oral hygiene (Silness-Löe Plaque index). Saliva samples were collected and tested for unbounded cortisol level using DRG® Salivary Cortisol ELISA kit (SLV-2930).
Appropriate statistical procedures were applied to handle the data, so the following results were found:
1. There were no statistically significant differences existed between the two groups as regard the age or gender (p= 0.613 and 0.655 respectively), indicating homogeneity between the two groups in relation to age and gender.
2. There was a statistically significant differences existed between the two groups as regards mother’s education (p=0.035) and father’s education (p=0.037). The parents of children with ECC had lower education level if compared to parents of caries fee children. Children with paternal education above average had 5.464 times more risk to develop dental caries than those with paternal higher education level (p=0.006, 95% CI= 1.63-18.36).
3. There was a significant difference between the two groups as regard the maternal occupation (p=0.035). Most of the mothers of children with ECC were either non-working (47.5%) or had a heavy work (40%). On the other hand, 37.5% of the mothers of caries free children have clerical work.
4. Most of fathers of children with ECC (57.5%) were smokers, while only 35% of the fathers of caries free children were smokers (p=0.044). Children with smoker fathers had 2.51 times more risk to develop dental caries than those with non-smoking fathers (p= 0.046, 95% CI= 1.019-6.198).
5. Having learning disabilities was reported by 32.5% of children with ECC compared to 12.5% of caries free children. The difference was statistically significant (p=0.032). Children had learning disabilities had 3.37 times more risk to develop caries than those children had no learning disabilities (p= 0.038, 95% CI =1.070-10.613).
6. The presence of electronic devices and video games at home was reported by 80% of children with ECC and 62.5% of caries free children (p=0.084). Children using electronic devices and video games at home had a higher risk to develop ECC than those children who did not use electronic devices and video games at home (OR= 2.4) However, the difference is approaching but did not reach a significant level (p=0.088, 95% CI =0.879-6.557).
7. The mean Epworth Sleepiness score in children with ECC was significantly higher (9.10 ± 5.15) than that of caries free children (6.08 ± 4.47) (p=0.007). Children with mild sleep disturbance had 6.182 times more risk to develop dental caries than those with normal range of sleepiness (p=0.009, 95% CI= 1.564-24.429).
8. Sleeping with bottle or food in the mouth was reported by 25% of children with ECC compared to only 7.5% of caries free children, the difference was a statistically significant (p=0.034). Children sleeping with bottle or food in their mouth had 4.11 times more risk to develop caries than those children did not have this habit (p=0.044, 95% CI= 1.037-16.295).
9. Drinking milk or eating dairy products 2 to 5 times weekly may be considered a protective factor against dental caries (p=0.032, 95% CI= 0.084-0.891).
10. The mean Silness and Loe Plaque index in children with ECC was significantly higher (1.28 ± 0.51) than that of caries free children (0.34 ± 0.37) (p<0.001). The plaque index is a risk factor for development of caries (OR= 52.20, 95% CI= 10.63-256.34).
11. The mean salivary cortisol level in children with ECC (0.67 ± 0.23 µg/dl) is significantly higher that of caries fee children (0.50 ± 0.22 µg/dl) (p=0.003). the salivary cortisol level as stress biomarker is a significant risk factor associated with development of early childhood caries (OR= 10.545; 95% CI: 3.73-29.84).
12. Eighty percent of children with ECC had salivary cortisol level > 0.57 µg/dl which was more than double the percentage of caries-free children in control group (27.5%) that had salivary cortisol level > 0.57. The difference was statistically significant (p<0.001). Concerning the risk of caries, children with salivary cortisol level > 0.57 µg/dl had revealed a significant risk for caries (OR= 10.545; 95% CI: 3.73-29.84) compared to those with salivary cortisol ≤ 0.57 µg/dl.
13. Significant correlation could be detected between severity of sleep disturbance (Total Epworth Scale) and salivary cortisol concentrations (µg/dl) in children with caries. Pearson’s correlation was positive, intermediate (r = + 0.5) and significant (p= 0.001). So, with increase in sleep disturbance, the salivary cortisol increases which as well elevates the chance of dental caries.
14. In univariate regression, significant association was observed with father smoking, having learning disabilities, total Epworth score, sleeping with bottle /food in the mouth, Silness and Loe plaque index and salivary cortisol level (>0.57µg/dl). Silness and Loe plaque index and salivary cortisol level (>0.57µg/dl) were associated with higher odds of ECC (OR= 8.671 and 10.545).
15. In multivariate regression, father smoking had an OR= 5.791 (p = 0.030), sleeping with bottle /food in the mouth had an OR = 8.481 (p =0.027), Silness and Loe plaque index had an OR = 6.681 (p = 0.001) and salivary cortisol level (>0.57µg/dl) had the highest odds off ECC (OR = 9.649, p = 0.003).
16. The mean salivary cortisol level adjusted for the effect of father smoking, sleeping with bottle /food in the mouth, and plaque index, was significantly higher in children with ECC (0.69 µg/dl) compared to that of caries free children (0.51 µg/dl) (p=0.009).
17. The significant association between the salivary cortisol level and ECC at both univariate and multivariate logistic regression analysis indicates that salivary cortisol is an independent stress biomarker in relation to early childhood caries.
Based on the results of the current study it is concluded that salivary cortisol level as an environmental stress biomarker is associated with ECC with higher levels detected in children with ECC compared to caries-free children. This association has implications for health education about the role of environmental stress factors in ECC and for pediatric dentists regarding caries risk assessment.
In the light of the results of the present study it is recommended that pediatric dentists and public health specialists should collaborate to establish education sessions for family members and caregivers in the kindergarten, schools and clubs to raise their knowledge and awareness about environmental stress factors and their relation to ECC and how to reduce them. They should also help teachers identify psychological issues among the children whom they teach, to allow the early detection of stress factors at school and the introduction of the required actions.