Aim This was to study children with early detected externalising behaviour problems compared to matched controls regard- ing oral health, oral health risk behaviour and the parental evaluation of the child’s oral health and dental care. Methods Children aged 10–13 years and with externalising behaviour problems, were compared to matched controls. Behav- ioural characteristics were based on the Strength and Difficulties Questionnaire. The children and their parents completed questionnaires regarding dental fear, tooth brushing, dietary habits and evaluation of oral health and dental care. Data on dental caries risk assessments, caries, behaviour management problems and dental trauma were obtained from dental files. Results There were no differences in caries prevalence in children with early detected externalising behaviour problems, com- pared to controls. However, the former group consumed more sweet drinks when thirsty and brushed their teeth fewer than twice daily; they also had more dental trauma in both dentitions and a higher risk range for dental fear, compared to controls. Conclusions This study points out potential oral health risk factors in children with early-detected externalising behav- iour problems. Although no difference in caries prevalence was observed, externalising behaviour may affect oral health. Therefore, dental professionals should support the families and the children to preserve dental health by offering increased prophylactic measures. There were no differences between children with externalising behaviour problems, compared with controls, regarding the parent evaluation of their child’s dental health. However, more parents in the study group evaluated the dental care as poor or not functioning. Keywords Child behaviour · Conduct problems · Dental caries · Dental fear · Dental trauma · Disruptive behaviour disorder Introduction problem behaviour is between 10 and 20% in children and adolescents (Ogundele 2018). Childhood behaviour prob- A considerable number of children and adolescents suffer lems, such as hostile aggression and hyperactivity, are unde- from emotional and behavioural problems. According to a sired due to norms of conventional society and defined as British review the prevalence of having signs of significant behaviour that is socially a problem. Externalising behaviour problems (EBP) include attention deficit hyperactivity dis- order (ADHD) problems (inattention, hyperactivity/impul- * M. Staberg sivity), as well as disruptive, oppositional, aggressive, and email@example.com conduct disorder behaviour (Bloomquist and Schnell 2002). Externalising behaviour in children has been shown to Department of Pediatric Dentistry, Institute of Odontology, influence both dental care and oral health (Staberg et al. The Sahlgrenska Academy, University of Gothenburg, P.O. Box 450, 405 30 Gothenburg, Sweden 2014a, b). An oral health risk behaviour can be expressed as a child brushing its teeth less than twice a day, and con- Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, suming more sweets and sweetened drinks several times University of Gothenburg, Gothenburg, Sweden a day. Department of Clinical Neuroscience, Karolinska Institutet, Therefore, it is important to establish good routines in Stockholm, Sweden childhood, to promote and improve oral health. Good oral Gillberg Neuropsychiatry Centre, Institute of Neuroscience health habits can continue throughout adulthood, giving and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Vol.:(0123456789) 1 3 178 European Archives of Paediatric Dentistry (2018) 19:177–186 a lifelong protection from dental diseases (Loe 2000; Subjects and methods Aunger 2007). In children with ADHD, the frequent consumption Study group of sugar can be difficult for the parents to deal with, and sometimes, the oral hygiene/tooth brushing is neglected The study group was comprised of 194 families with chil- (Staberg et al. 2014b). Among children with externalis- dren (10–13 years of age), whose parents participated in par- ing behaviour problems, those with an elevated caries risk ent management training (PMT) programs, evaluating early have been shown to have more impulsivity and conduct intervention for children with externalising behaviour prob- problems, compared to children with low caries risk (Sta- lems, previously described in detail (Staberg et al. 2016). berg et al. 2016). Briefly, 796 families, who experienced some degree of Children with traumatic dental injuries (TDI) have more externalising behaviour problem with their child (e.g., par- hyperactive symptoms than children without dental trauma ents with children in conflict with peers, parents or other (Herguner et al. 2015). The frequency of dental injuries adults, protesting against demands, often restless, hav- in children with ADHD peaks at the age of 10–12 years, ing friends with bad influence or having been involved in with the main causes of dental injuries being falls, colli- vandalism, shoplifting or truancy) responded to advertise- sions with objects, violence and traffic accidents (Avsar ments about participating in the study. After obtaining writ- et al. 2009). ten informed consent, the parents were asked to fill out the A Swedish review article has found a relationship Strengths and Difficulties Questionnaire (SDQ) (Goodman between dental fear and children with externalising problems 1997). Children below the cut-off point, the criteria for (Klingberg and Broberg 2007). Dental anxiety and behaviour clinically relevant problems (less than three points on the management problems are higher in children with ODD/ conduct problem subscale of the SDQ), and children with ADHD, than in children without ODD/ADHD (Aminabadi autism, obsessive compulsive disorder or ongoing psychiat- et al. 2016), and may delay or prevent dental treatment. ric treatment, were excluded. Finally, 231 families entered All children in Sweden are assessed for caries risk at the study; 3 children were excluded due to missing dental their regular dental examinations, with the outcome used records, and 34 children were excluded due to missing ques- for caries preventive planning for those children who need tionnaire and/or dental data, resulting in a total number of it the most (Twetman et al. 2013). Therefore, it is important 194 children (113 boys, 81 girls). A flow chart illustrating to evaluate if, and in what way, oral health differs between the recruitment process and dropouts is presented in Fig. 1. children with early-detected externalising problems, and matched controls. In cases where it is indicated, this infor- mation can be used to design and implement early, effec- Control group tive interventions and provide active help for children with externalising problems, and their parents. For each child in the study group, three possible matched The aim of the present paper was to study children with controls, with the same age, gender, dental clinic and early-detected externalising behaviour problems, compared socioeconomic area (residential address), were identified. to matched controls, regarding oral health, oral health risk The first one, of the three matched controls, accepting the behaviour and the parent’s evaluation of the child’s oral invitation was selected. It was possible to recruit 194 chil- health and dental care. dren into the study group and 153 into the control group (63 girls and 90 boys). All parents were asked to fill out the same questionnaire (SDQ) as the study group. Children with a value ≥ 3 or more on the conduct problem subscale Hypothesis of the SDQ, (six girls, eight boys), were excluded to ensure a control group without externalising behaviour problems, Children with externalising behaviour problems have a risk resulting in 139 controls (57 girls, 82 boys) (Fig. 1). behaviour influencing caries, dental trauma, dental fear, and poorer oral health routines (e.g., less frequent tooth brushing habits and more frequent cariogenic dietary habits compared Instruments to controls). Background information questionnaires The parents were asked to provide background informa- tion through a questionnaire, regarding dental care and the 1 3 European Archives of Paediatric Dentistry (2018) 19:177–186 179 Fig. 1 Flow chart describing the STUDY GROUP CONTROL GROUP recruitement of patients to the study group and to the control group, respectively. SDQ Interested in participating Strengths and Difficulties Ques- No.= 796 tionnaire, SDQ-CD Strengths and Difficulties Questionnaire Declined after No reached or conduct problems information excluded No.= 250 No.= 60 Sent SDQ No.= 486 No answer to SDQ No.= 112 Not reaching cut off ≥3SDQ-CD No.= 131 Interrupted after SDQ No.= 12 SDQ answers No.= 231 Incomplete Missing dental questionnaires records No.= 34 No.= 3 3 matched controls Study Group to each individ First to answer with SDQ No.= 194 No.= 153 Girls = 81; Boys = 113 Over cut off ≥3SDQ-CD No.= 14 Control Group No.= 139 Girls = 57; Boys = 82 parent’s evaluation of their child’s oral health. The child true; 1 = somewhat true; 2 = certainly true). All subscales, responded to a questionnaire regarding dental fear, tooth with the exception of prosocial behaviour, are summed brushing frequency, and dietary habits. together to a total difficulties score. A high score on the Prosocial Behaviour subscale indicates a strength, while The Strengths and Difficulties Questionnaire (SDQ) high scores on the other four subscales indicate difficulties. The Strengths and Difficulties Questionnaire (Goodman Dental fear (CFSS‑DS) 1997) is a frequently used screening instrument for child and adolescent mental health, throughout the world, with good The Dental Subscale of the Children’s Fear Survey Schedule psychometric properties (Goodman 2001). The parental ver- (CFSS-DS) is a well-known instrument for assessing dental sion of the SDQ for children 4–16 years, used in this study, fear in children, initially presented by Cuthbert and Mela- can be completed within a few minutes and is validated for med (1982). The CFSS-DS consists of 15 items, related to Swedish conditions (Smedje et al. 1999). various aspects of dental treatment. Each item can be scored The SDQ symptom scales contain 25 items divided into on a 5-point scale from 1 (not afraid) to 5 (very afraid). Total five subscales, namely, Emotional Symptoms, Conduct scores range from 15 to 75. Problems, Hyperactivity-Inattention, Peer Problems, and The cut-off score of 38 or higher on the CFSS-DS has Prosocial Behaviour. A 3-point Likert scale is employed to been commonly used to define dental fear, irrespective of indicate how each attribute applies to the target child (0 = not age, gender, and informant. In the present study, the cut-off 1 3 180 European Archives of Paediatric Dentistry (2018) 19:177–186 score was set to ≥ 32 points, indicating “borderline” or “risk corrected p-values were calculated by the multitest pro- for dental fear”, which has been used in previous studies (ten cedure in SAS Version 9.3 (SAS institute. Ink, Cary, NC, Berge et al. 2002; Fagerstad et al. 2015). Some children have USA). no, or very limited, experience of invasive dental treatment A logistic regression was used to assess the association and are therefore unable to answer all 15 questions in the between children with externalising behaviour problems survey on the CFSS-DS. Where responses to one or a maxi- and dental caries, traumatic dental injuries, oral health risk mum of three survey questions were missing then an average factors, dental fear and parental evaluation of dental care, score was calculated. That score was used, thereby, so that and the child’s oral health, compared to controls. Data were a total of CFSS-DS could still be established. adjusted for age and gender. The results were expressed as odds ratio (OR) with a 95% confidence interval. For multiple interferences, the significance level was adjusted according Dental records to the Bonferroni–Holm method and in the results, both un- adjusted and adjusted values are presented. Data from dental records regarding caries in the primary teeth (deft, 12 teeth canine, first and second primary molars), caries in the permanent teeth (DMFT) and initial caries in Ethical considerations first permanent molars, were compiled. Since children are growing individuals with different dental stages, ages, and The study was approved by the Ethical Committee in Upp- number of teeth, caries in the first permanent molar was sala (dnr 2010/119). All families participating in the pro- chosen as an expression for the caries situation. ject were given written information. Written consent from All Swedish children are assessed for caries risk at their the participating families was received, in order to acquire dental examinations. Data regarding caries risk was com- access to their child’s dental records. piled from the dental file system used, by the Public Den- tal Service in the Region of Västra Götaland. The caries risk assessment is set by a combination of the computerised Results algorithm-based system R2 (Andas and Hakeberg 2014), and a clinical assessment made by each child’s regular dentist, In order to make the presentation of the results more explicit, according to regional standardised guidelines by the Region the results are shown in four different tables, including un- of Västra Götaland. Those guidelines can be obtained by adjusted and adjusted p-values. contacting the corresponding author. The caries activity, based on new caries lesions and car- ies progression, is estimated in combination with modifying Study group vs. control group factors such as diet, fluoride, oral hygiene, previous caries experience, age, and medical risk recorded. The R2 system Gender and year of birth finally defines the caries risk as low, intermediate, or high. In order to identify children at risk, the caries risk data were The distribution of age and gender in the study group and the dichotomised to low and elevated caries risk. The intermedi- control group were approximately similar. The mean age in ate and high caries risk group together, formed the elevated the study group was 11.7 years (SD 1.6) and the correspond- caries risk group. ing values in the control group were 11.6 years (SD 1.7). Data regarding dental trauma in the primary and perma- nent teeth, behaviour management problems (BMP), defined Caries and caries risk assessment (R2) as notes in the dental records, clearly expressing severe dis- ruptive behaviours, were also collected from dental files. Caries In this study all dental files have been reviewed and read through from the very first dental visit. No statistical significant difference was found regarding car - ies in the primary and permanent teeth, and caries in the Statistical analysis primary and/or permanent dentition, and number of decayed, missing/l fi led r fi st permanent molars, including initial caries Statistical analysis was performed using the statistical between the two groups. software R (GNU General Public License, Free Software Upon entering the study, 28.9% of the children in the Foundation, Inc., Boston, USA) and the Statistical Package study group had filled or decayed first permanent molars, for Social Sciences (SPSS version 21). Bonferroni–Holm compared to 18.7% of the controls. The difference was statistically significant in the logistic regression analysis 1 3 European Archives of Paediatric Dentistry (2018) 19:177–186 181 Table 1 The upper part of the table shows the number of children filled first permanent molars in the study and control groups, the dis- with primary dental caries and permanent dental caries, caries in the tribution in low and elevated caries risk groups, respectively, when primary and/or permanent dentitions, number of decayed/missing/ entering the study Study group Control group Total n (%) n (%) n (%) Caries Caries in primary teeth deft = 0 137 (70.6) 108 (77.7) 245 (73.6) deft > 0 57 (29.4) 31 (22.3) 88 (26.4) Caries in permanent teeth DMFT = 0 130 (76.0) 102 (73.4) 232 (69.7) DMFT > 0 64 (33.0) 37 (26.6) 101 (30.3) Caries in primary and/or permanent dentition deft and DMFT = 0 96 (49.5) 82 (59.0) 178 (53.5) deft and DMFT > 0 98 (50.5) 57 (41.0) 155 (46.5) Number of decayed/missing/filled first permanent molars DMFT = 0 138 (71.1) 113 (81.3) 251 (75.4) DMFT > 0 56 (28.9) 26 (18.7) 82 (24.6) Number of decayed/missing/filled first permanent molars including initial caries DMFTi = 0 111 (57.2) 93 (66.9) 204 (61.3) DMFTi > 0 83 (42.8) 46 (33.1) 129 (38.7) Caries risk assessment Low risk 138 (71.1) 114 (82.0) 252 (75.7) Elevated risk 56 (28.9) 25 (18.0) 81 (24.3) n OR CI p log reg p log reg B-H Caries in primary teeth 333 1.45 0.88–2.42 n.s n.s Caries in permanent teeth 333 1.35 0.82–2.22 n.s n.s Caries prim and/or perm dent 333 1.46 0.94–2.28 n.s n.s DMFT 333 1.78 1.04–3.09 0.038 n.s DMFTi 333 1.51 0.95–2.43 n.s n.s Caries risk assessment 333 2.42 0.98–6.86 n.s n.s Percentage within brackets (Deft decayed/extracted/filled primary teeth, DMFT decayed/missing/filled first permanent molars, DMFTi decayed/ missing/filled first permanent molars and initial caries) The lower part of the table shows the results from the logistic regression [n number, n.s. non-significant, OR odds ratio, CI confidence interval (95%), p log reg p-value logistic regression, p log reg B–H p-value logistic regression with Bonferroni–Holm correction] (p = 0.038), however, after Bonferroni–Holm correction Oral health behaviour (BH-c), the difference was not significant. The OR for DMFT > 0 was 1.78 (Table 1). Tooth brushing Caries risk assessment (R2) More children with externalising behaviour brushed their teeth less than twice a day, and when compared to the con- In the study group, 28.9% of the children had an elevated trols, the difference was statistically significant (p = 0.0007 caries risk, compared to 18% in the control group, and the after BH-c p = 0.01) (Table 2). The OR for tooth brushing difference was not statistically significant. The OR for ele- less than twice a day was 2.80. vated caries risk was 2.42 (Table 1). Drinking when thirsty Children with externalising behaviour preferred drinks other than water or milk, more often when thirsty, 1 3 182 European Archives of Paediatric Dentistry (2018) 19:177–186 Table 2 The upper part of the table shows the frequencies of the risk factors connected to oral health behaviour in children with externalising behaviour problems compared to controls Study group Control group Total n (%) n (%) n (%) Tooth brushing TB < 2 times/day 56 (28.9) 18 (12.9) 74 (22.2) TB ≥ 2 times/day 138 (71.1) 121 (87.1) 259 (77.8) Drink when thirsty Water/milk 144 (74.2) 125 (89.9) 269 (80.8) Other than water/milk 50 (25.8) 14 (10.1) 64 (19.2) Sweet /soft drinks at meals Never, seldom, 1/week 116 (59.8) 98 (70.5) 214 (64.3) Several times /week/daily 78 (40.2) 41 (29.5) 119 (35.7) Sweets Never, seldom, 1/week 127 (65.5) 103 (74.1) 230 (69.1) Several times /week/daily 67 (34.5) 36 (25.9) 103 (30.9) Cakes, buns biscuits Never, seldom, 1/week 163 (84.0) 109 (78.4) 272 (81.7) Several times /week/daily 31 (16.0) 30 (21.6) 61 (18.3) n OR CI p log reg p log reg B-H Tooth brushing 333 2.80 1.58–5.19 0.0007 0.010 Drink when thirsty 333 3.13 1.68–6.19 0.0005 0.009 Sweet/soft drinks at meals 333 1.61 1.02–2.58 0.0447 n.s Sweets 333 1.50 0.93–2.45 n.s n.s Cakes, buns, biscuits 333 0.69 0.39–1.21 n.s n.s Percentage within brackets The lower part of the table shows the results from the logistic regression [n number, n.s. non-significant, OR odds ratio, CI confidence interval (95%), p log reg p-value logistic regression, p log reg B–H p-value logistic regression with Bonferroni–Holm correction] compared to the controls. The logistic regression analysis Sweets showed a statistically significant difference (p = 0.0005; after BH-c p = 0.009) (Table 2). The OR for preferring Children with externalising behaviour more often con- other beverages than water or milk when thirsty was 3.13. sumed sweets several times per week or daily compared to the controls (34.5 vs. 25.9%), but the difference was Sweet/soft drinks at meals not statistically significant. The OR for consuming sweets several times /week/daily was 1.50 (Table 2). In the study group, 40.2% of the children frequently (sev- eral times/week/daily) drank sweetened drinks at meals, compared to 29.5% in the control group, however, the dif- Cakes, buns, biscuits ference was not statistically significant. The OR for drink - ing sweetened/soft drinks at meals several times a week/ No differences were found regarding the consumption of daily was 1.62 (Table 2). cakes, buns and biscuits between the two groups (Table 2). 1 3 European Archives of Paediatric Dentistry (2018) 19:177–186 183 Table 3 The upper part of the table shows the frequencies of traumatic dental injuries (TDI) in the primary and permanent dentitions in children with externalising behaviour problems compared to controls Study group Control group Total n (%) n (%) n (%) TDI both dentitions No TDI 94 (48.5) 97 (69.8) 191 (57.4) TDI 100 (51.5) 42 (30.2) 142 (42.6) TDI primary dentition No TDI 132 (68.0) 116 (83.5) 248 (74.5) TDI 62 (32.0) 23 (16.5) 85 (25.5) TDI permanent dentition No TDI 134 (69.1) 114 (82.0) 248 (74.5) TDI 60 (30.9) 25 (18.0) 85 (25.5) n OR CI p log reg p log reg B-H TDI both dentitions 333 2.47 1.57–3.93 0.0001 0.002 TDI primary dentition 333 2.42 1.42–4.22 0.0014 0.020 TDI permanent dentition 333 2.04 1.21–3.52 0.0082 n.s Percentage within brackets The lower part of the table shows the results from the logistic regression [n number, n.s. non-significant, OR odds ratio, CI confidence interval (95%), p log reg p-value logistic regression, p log reg B–H p-value logistic regression with Bonferroni–Holm correction] In the study group and the control group, 15.5% and 2.2% Traumatic dental injuries of the children had a CFSS-DS value ≥ 32, respectively, and were thus classified as having a higher risk for dental fear. There were more children with externalising behaviour who The difference was statistically significant (p = 0.0005; had traumatic dental injuries (TDI) in both dentitions, com- after BH-c p = 0.009; OR 8.61). No correlation was found pared to the controls (51.5 and 30.2%, respectively). The between risk for dental fear and TDI. logistic regression showed a statistically significant differ - ence (p < 0.0001; after BH-c p = 0.002; OR 2.47) (Table 3). Parental evaluation of dental care and dental health TDI in the primary dentition was statistically significantly more common among the externalising children, compared There was no statistical difference between children with to the controls (32 vs.16.5%, p = 0.0014; after BH-c p < 0.02; externalising behaviour problems, compared to controls, OR 2.42). In the permanent dentition, TDI was significantly regarding the parent’s evaluation of their child’s dental more common among the externalising children (30.9 vs. health. The OR value was 2.34 (Table 4). There were more 18%; p = 0.008; OR 2.04), however, the difference was non- parents in the study group evaluating the dental care as poor significant after BH-c (Table 3). or not functioning (p = 0.03; after BH-c non-significant; OR 4.05) (Table 4). Behaviour management problems (BMP) The frequency of BMP was 10.3% in the study group and Discussion 2.2% in the control group, and the difference was statistically significant (p < 0.009; after BH-c non-significant; OR 5.25). This study has shown that the caries prevalence was not higher in children with early-detected externalising behav- iour problems, compared to the controls. However, it was Risk for dental fear (CFSS‑DS) more common that these children brushed their teeth fewer than twice a day, and consumed more sweetened drinks. There were 10 children in the study group with dental fear These individual risk factors might lead to a future increased (CFSS-DS ≥ 38), however, none in the control group reached risk of being in the elevated caries risk group. Furthermore, a value of CFSS-DS ≥ 38. The mean value for the CFSS-DS these children had more dental trauma in both dentitions, score in the study group was 24.07 (SD 7.403), and in the and a higher risk range for dental fear, compared to the control group 20.16 (SD 4.677). controls. 1 3 184 European Archives of Paediatric Dentistry (2018) 19:177–186 Table 4 The upper part of the table shows the frequencies of behav- of dental care and the child’s dental health in children with externalis- iour management problems (BMP), risk for dental fear according to ing behaviour problems compared to controls Children’s Fear Survey Schedule (CFSS-DS) and parental evaluation Study group Control group Total n (%) n (%) n (%) Behaviour management problems No BMP 174 (89.7) 136 (97.8) 310 (93.1) BMP 20 (10.3) 3 (2.2) 23 (6.9) Risk for dental fear CFSS-DS < 32p 164 (84.5) 135 (97.1) 299 (90.0) CFSS-DS ≥ 32p 30 (15.5) 3 (2.2) 33 (9.9) Dental health (parental evaluation) Very good 95 (52.5) 97 (69.8) 192 (60.0) Good/poor 86 (47.5) 42 (30.2) 128 (40.0) Dental care (parental evaluation) Well-functioning 178 (91.8) 136 (97.8) 314 (94.3) Poor 16 (8.2) 3 (2.2) 19 (5.7) n OR CI p log reg p log reg B-H BMP 333 5.25 1.75–22.63 0.0086 n.s Risk for dental fear 332 8.61 2.96–36.60 0.0005 0.0089 Evaluation by parents Dental health 320 2.34 0.68–10.71 n.s n.s Dental care 333 4.05 1.31–17.66 0.0289 n.s Percentage within brackets The lower part of the table shows the results from the logistic regression [n number, n.s. non-significant, OR odds ratio, CI confidence interval (95%), p log reg p-value logistic regression, p log reg B–H p-value logistic regression with Bonferroni–Holm correction] A strength of the present study was the selection criteria the dental professionals have great opportunities to assist of including families from different socio-economic areas, and support the families by offering an increased number of and the use of the validated instruments, SDQ and CFSS- contact times and prophylactic measures. DS. In this study, the Bonferroni–Holm correction was used, Poor oral hygiene, tooth brushing and consumption of but the unadjusted values are also presented, adding valuable sweetened beverages, identified in the study group com- information. pared to controls, may increase the risk for future caries Children with early-detected externalising behaviour development. This is in agreement with the results of a problems had fared well in terms of caries. There was no Norwegian study in pre-school children (Wigen and Wang significant difference regarding caries, compared to the 2015). Previous studies have shown an association between controls, which is in accordance with a previous study of ADHD and less frequent tooth brushing, irregular eating young children (aged 3–8 years) (Lorber et al. 2014). In a times, unhealthy food, and the increased consumption of study of children with ADHD at age 13 years, the caries soft drinks/sweetened beverages (Ptacek et al. 2014; Staberg prevalence was not higher compared to controls (Blomqvist et al. 2014b). et al. 2007). However, teenagers (aged 17 years) with ADHD Oral health and daily tooth brushing routines from the had a higher prevalence of caries, compared to the controls parents to the child are usually established early in life (Blomqvist et al. 2011). and are resistant to changes (Aunger 2007). Healthy eating The OR value of 2.42 in the caries risk assessment found requires planning, organisation and self-regulation, which in the present study indicated a need for special attention may be more difficult for teenagers with externalising regarding caries in children with externalising behaviour. behaviour problems. As a child grows older and becomes Since the individual risk factors may lead to a higher future more independent, the risk factors may increase when caries activity during adolescence, these children should supervision from the parent’s decreases. belong to the elevated caries risk group. This study has In this study, the frequency of traumatic dental inju- pointed out potential risk factors in children with early- ries was higher among children with externalising behav- detected externalising behaviour problems. This means that iour problems, compared to the controls. The prevalence 1 3 European Archives of Paediatric Dentistry (2018) 19:177–186 185 of dental trauma in both dentitions, 51.5%, was higher Conclusions than the 42.9% found among 11–13-year-old in a previ- ous Swedish study on dental trauma (Oldin et al. 2015). This study has pointed out potential oral health risk fac- Therefore problem behaviour can be an additional risk tors in children with early-detected externalising behaviour factor for traumatic dental injuries (TDI), which is in line problems, compared to a matched control group. Although with a previous study (Oldin et al. 2015). Furthermore, no difference in caries prevalence was observed, external- the children at risk for dental fear, CFSS-DS ≥ 32, had not ising behaviour may affect oral health, caries, and dental been exposed to more dental trauma compared to those trauma, and may increase the risk for dental fear. By paying without dental trauma. attention to the child’s behaviour and listening to the par- The children in the study group had to have a value of ents during the dental visit, the dental teams may be able to 3 or more on the SDQ-CD scale to be regarded as having identify externalising children. This means the dental pro- a clinical relevant behaviour problem. Due to the child’s fessionals have great opportunities to assist and support the impulsivity and conduct problems, this risk for “acting out” families by offering an increased number of contact times behaviour may lead to more arguments with friends and and prophylactic measures. In this way, dental care may intentional or unintentional injuries. preserve the dental health of the children. There were no The child’s activities and the environment, e.g., the differences between children with externalising behaviour child’s sociability, may be another determining risk factor problems, compared to the controls, regarding the parent’s for TDI, which is in agreement with a recently presented evaluation of their child’s dental health. However, in the Swedish study (Oldin et al. 2015). Impulsivity and attention- study group, more parents evaluated the dental care as poor related problems, associated with externalising behaviour or not functioning. problems, may influence the child’s inhibition systems and limit the child’s risk assessment, leading to activities without thinking of consequences and thereby, increasing the risk Clinical implications for dental trauma. Studies from the UK have established a relationship This study has shown that externalising behaviour ought to between emotional disorders and unintentional injuries, be added to the repertoire of factors considered for caries where children with disruptive behaviour had an increased risk evaluation. Since the parents evaluated the dental care risk for injuries, as a result of their hyperactivity and emo- as poor or not functioning, the dental professionals should tionality (Lalloo et al. 2003; Rowe et al. 2004). Due to the consider this fact when treating and planning dental care. trauma risk, interceptive orthodontic treatment in children Furthermore, externalising children with a large overjet with externalising behaviour and a large incisal overjet could should be offered interceptive orthodontic treatment. be a good preventive measure, since the incisal overjet has The collaboration in prevention between the Public Den- been shown to be a risk factor for TDI (Forsberg and Ted- tal Service, the school, and the social services, described in estam 1993). this study, is unique for Swedish conditions. A high OR value for behaviour management problems If the regular dental service identifies children with exter - was found among the children with externalising behaviour nalising behaviour problems, this could be valuable for their problems in this study. The connection between BMP and oral health, and in addition, may initiate a contact between externalising behaviour are in line with earlier findings in the family and the social services for support and help, such a Swedish study (Blomqvist et al. 2004). One factor that as participating in parent management training programmes. can explain the behaviour management problems is the age Acknowledgements This study was supported by the region of Västra of the child, since BMP has been shown to decline with Götaland, and the Swedish National Board of Health and Welfare. age (Klingberg et al. 1994). The BMP could also possibly be explained by the dental team’s inexperience of treating Compliance with ethical standards externalising children (Staberg et al. 2014a). Dental teams, who are able to develop warm and supportive relationships Conflict of interest The authors declare that there were no conflicts with these children, have the potential to create a well-func- of interest. tioning and positive dental experience, and reduce the risk for a negative oral health outcome, which has been shown Open Access This article is distributed under the terms of the Crea- tive Commons Attribution 4.0 International License (http://creat iveco in the present study, where the parents were satisfied with mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- the dental care. tion, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 1 3 186 European Archives of Paediatric Dentistry (2018) 19:177–186 Klingberg G, Vannas Lofqvist L, Bjarnason S, Noren JG. 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European Archives of Paediatric Dentistry – Springer Journals
Published: May 15, 2018
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