Monday, April 3, 2017 Instructions for questions 1-3 • Include your name and the CI, Hypothesis Test or Sample Size assignment that you were given; I don’t want to have to look-up the HT you were assigned. • Pick 2 from questions 1, 2, and 3 to answer. For example, you can pick to do a Hypothesis Test and a Confidence interval that you were assigned, or a Confidence interval and a sample size, …. 2 out of the 3. • Your write up for 2 of the 3 questions 1-3 should be no more than 1 page total; I won’t grade anything after the 1st page. • The scenarios used in your write ups do not have to be real but should match the type of data for the hypothesis test that you are assigned. For example, if you are assigned a one sample mean HT, you should come up with an example that uses continuous data. Assignments for questions 1-3 (pick 2) Write a different example for each assignment that you pick. You do not need to make up data, but you do need to make up statistics and use these for the templates or sample size calculations. For example, if you are assigned a 1sample mean for a confidence interval, you have to pick an example (could be related to your research, nor not), pick a sample size, mean, and standard deviation. With these calculate a 95% confidence interval and report all of this using mostly words – you do not need to include the template. Be sure to tell me what assignment your write up reflects – this is really important. Don’t use examples from class notes – use your imagination and if that doesn’t help, look for some published journal articles and grab some appropriate numbers and statistics from there. Last Name Alsulaiman Q1: hypothesis test Q2: Confidence interval the mean of a difference Q3: Sample size Hypothesis test 2 proportions Goodness of fit 4. The data file contains 62 observations and the variables age, male, hypo, hyper, and linWidth. This comes from the same data set that we used in class 2 weeks ago, but again, it is only some of the original data. Calculate summary statistics for each column (you decide what statistics are appropriate and informative) and then list some tests and confidence intervals that you would do if you are interest in whether linWidth is associated by hypo/hyper classifications and also whether age and male affect linWidth 5. Using your own words (and not the words of the journal article), interpret the results in Table 2 of this article for the 1st outcome, condition of the teeth is fair or poor for the unadjusted model and for the adjusted model but only down through the income variable (so include number of ACEs, age, sex, and income) in your write up. Bright, M. A., Alford, S. M., Hinojosa, M. S., Knapp, C., & Fernandez-Baca, D. E. (2015). Adverse childhood experiences and dental health in children and adolescents. Community Dent Oral Epidemiol, 43, 193-199. (thanks to Saurabh Mankotia for finding this article!) To summarize: You need to turn in answers to 2 of the 3 personal assignments for Q1-Q3. I will only grade up to 1 page of write up for these. Next, you need to do summary statistic calculations and report them for Q4 and then write about what methods you would use to analyze the data further. This should take about .5 page. And then for Q5, get the article and write a brief discussion of the results for the 1 outcome as described in Q5. This could be another .5 page. age male 16 15 31 15 38 29 62 50 50 49 49 49 45 44 44 43 41 37 36 32 29 27 26 17 18 34 18 25 52 35 33 61 60 56 17 15 57 56 50 48 44 40 39 30 27 18 hypo 1 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 1 1 1 0 0 0 0 1 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 hyper 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 linWidth 23,2 25,4 31,8 27,1 32 21,8 31,4 32 30,2 21,8 25,9 27,6 24,7 30,2 20,7 33,9 26,7 24,3 30,7 29,2 28,1 33,2 32,6 27,5 29,9 29,4 30,4 25,7 16,4 34 29,5 21,8 22,2 26,5 25,5 28,3 15,1 29,4 23,2 27,9 25,3 27,7 24,1 21,9 19,9 28,9 22 56 30 60 14 30 13 40 25 27 60 31 43 17 22 28 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 21,3 22,3 25,3 33,8 28,1 18,9 24,6 28,6 28,5 23,6 31,2 22,5 20,9 28,2 35,5 28,4 Community Dent Oral Epidemiol 2015; 43; 193–199 All rights reserved Ó 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Adverse childhood experiences and dental health in children and adolescents Melissa A. Bright1, Shannon M. Alford1, Melanie S. Hinojosa2, Caprice Knapp3 and Daniel E. Fernandez-Baca1 1 Institute for Child Health Policy, University of Florida, Gainesville, FL, USA, 2 Department of Sociology, University of Central Florida, Orlando, FL, USA, 3 Department of Health Policy and Administration, The Pennsylvania State University, State College, PA, USA Bright MA, Alford SM, Hinojosa MS, Knapp C, Fernandez-Baca DE. Adverse childhood experiences and dental health in children and adolescents. Community Dent Oral Epidemiol 2015; 43: 193–199. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Abstract – Objective: This study seeks to explore the how specific toxic stressors, specifically adverse childhood experiences (ACEs), and their frequencies may be associated with tooth condition and the presence of caries. Methods: Data from the 2011–12 National Survey for Child Health (NSCH), a nationally representative survey of child health, were used in this study. Pediatric dental health was measured using parent report of two characteristics: condition of teeth and having a toothache, decayed teeth, and/ or unfilled cavities in the past 12 months. ACEs were measured by asking about a child’s exposure to the divorce of a parent, parental incarceration, domestic violence, neighborhood violence, drug and alcohol abuse, mental illness, and financial hardship. Analyses were adjusted by sociodemographic characteristics, healthcare access and utilization, and comorbid chronic conditions. Results: The presence of even one ACE in a child’s life increased the likelihood of having poor dental health. Additionally, having multiple ACEs had a cumulative negative effect on the condition of their teeth and the presence of dental caries (Odds Ratios 1.61–2.55). Adjusted models show that racial and socioeconomic factors still play a significant role in dental health. Conclusions: In addition to the known disparities in dental caries, this study demonstrates that there is significant association between childhood psychosocial issues and dental health. Preventive dental care should be considered incorporating the screening of multiple biological stressors, including ACEs, in routine dental visits as a means of identifying and reducing dental health inequities. Poor dental health, characterized by dental caries (i.e., tooth decay), periodontal disease, unfilled cavities, missing teeth, or toothache, can have serious implications for overall health. In children, having untreated dental caries and poor dental health is linked to lower weight (1), more school absences (2), poor school performance (3), and lower quality of life (4). Dental caries is generally preventable; however, in the United States, they are the most common pediatric disease. Among adolescents (aged 14–17), tooth decay is four times more common than asthma, affecting 50% of children in this age range (5). Additionally, tooth doi: 10.1111/cdoe.12137 Key words: pediatric dentistry; psychosocial aspects of oral health; stress Melissa A. Bright, Institute for Child Health Policy, University of Florida, PO Box 100177, Gainesville, FL 32610-0177, USA Tel.: +1 352-627-9467 Fax: +1 352-265-7221 e-mail: Mbright08@ufl.edu Submitted 24 March 2014 accepted 14 October 2014 decay affects more than 25% of preschool aged children (ages 2–5) (6). Consistent with patterns in general health outcomes, there are significant socioeconomic and racial disparities in the prevalence of dental caries. Children from racial and ethnic minority groups, particularly Black and Hispanic children, are more likely than their counterparts to have teeth in poor or fair condition (7), dental caries, untreated disease, and decayed teeth (8, 9). Children from single-parent households (10), as well as children from families with low household incomes, are more likely to have unmet dental 193 Bright et al. needs (11) and less likely to have preventative dental visits (12). Children who are not enrolled in dental insurance plans are more likely to have unmet dental needs than their insured peers (13, 14). Socioeconomically disadvantaged youth often experiences social stressors, such as dysfunctional family relationships and household dynamics (15), which may contribute to their increased likelihood for poor dental health. Exposure to social stressors is associated with increased activity of the neuroendocrine-immune stress response systems and subsequent increased susceptibility to disease (16). In asthmatic children, for example, low socioeconomic status was associated with increased production of cytokines implicated in immune responses found in asthma (17). Additionally, compared to high-socioeconomic-status children (aged 9–18 years), low-SES children demonstrated an increased production of cortisol, the primary hormonal output of the hypothalamic–pituitary–adrenal axis, over a two-year period (18). Given the prevalence and impact of poor dental health, it is surprising that research is limited. Experiences such as child abuse/neglect, parental divorce, domestic violence, caregiver mental illness, caregiver incarceration, exposure to drug/ alcohol abuse, and struggles with family income have been identified as toxic stressors based on their association with poor health outcomes. These events, often termed adverse childhood experiences (ACEs), are relatively prevalent in 50–65% of adults (19) and 90% of adolescents who are at risk for maltreatment (20), reporting at least one ACE in their lifetime. The health and behavior implications of ACEs have been well documented (19, 21). Compared to individuals who report no ACEs, adults who report experiencing at least one ACE are more likely to engage in high-risk behaviors (i.e., drug use, risky sexual behavior) and to suffer from mental (e.g., alcoholism, depression) and physical (e.g., liver disease, chronic lung disease) disorders (21–23). Additionally, there is a cumulative effect whereas a higher number of ACEs are associated with greater likelihood for poor health outcomes (19). Similar results have been found in studies of adolescents (24, 25). Compared to adolescents who reported no ACEs, adolescents who reported one or more ACE were more likely to have an injury that required a doctor, poor health, and experience somatic concerns (26). 194 Given the prevalence of poor dental health and social stressors among low-income children, and the link between social stressors and etiology of disease, the association between social stressors and pediatric dental health warrants examination. In this study, we investigate the association between parent-reported ACEs and pediatric dental health outcomes. Our specific objectives are to examine the following: (i) frequency of poor dental health, as measured by (a) having teeth in fair or poor condition and (b) having a toothache, decayed teeth, and/or unfilled cavities in the past 12 months, in children and adolescents, (ii) frequency of ACEs for children with poor dental health, and (iii) association between number of adverse childhood experiences and poor dental health outcomes in children. Method Sample Data from the 2011–2012 National Survey for Child Health (NSCH) were used (27). A project of the Child and Adolescent Measurement Initiative (CAHMI), this parent-report survey drawn from a random-digit-dial sample of landline and cellular telephone numbers. Eligible households included at least one resident child between 0 and 17 years of age. When there were more than one eligible child in the household, only one child was chosen. Respondents were required to be a parent or guardian with knowledge of the health and health care of the target child. In this sample, 68.6% of respondents were mothers (biological, step, foster, or adoptive), 24.2% were fathers, and 7.2% were other relatives or guardians.1 A total of 95 677 interviews were conducted across the United States with at least 1800 interviews being conducted per state and the District of Columbia. For purposes of this study, children must have been between 1 and 17 years of age and have natural teeth.2 These eligibility criteria resulted in 90 555 children in the current analyses. 1 Frequencies provided by the 011-2012 National Survey of Children’s Health Frequently Asked Questions. 2 Sixty-two (0.1%) children were excluded from the sample for having no natural teeth. Adverse childhood experiences and pediatric dental health Measurement Two items measuring dental health were used as outcome variables. One item measured overall condition of the child’s teeth: ‘How would you describe the condition of [CHILD’s NAME] teeth?’ Response options for this item included excellent, very good, good, fair, or poor. The second item measured more specific dental health: ‘During the past 12 months, did [CHILD’S NAME] have a toothache, decayed teeth, and/or unfilled cavities?’ Response options for this item were yes or no; responses of yes were used to indicate poor dental health. The primary predictor variables included seven items capturing ACEs. The adverse experiences included divorce of a parent, exposure to domestic violence, exposure to drug and alcohol abuse, exposure to mental illness, having a parent in jail, witnessing or being a victim of neighborhood violence, and household financial hardship. Respondents were asked whether their child had experienced each of these ACEs and could respond yes or no. Each item was coded such that affirmative responses indicated presence of the stressor. Details of these questions can be found on the Data Resource Center for Child and Adolescent Health website. Several additional items were added as covariates in adjusted models: sociodemographic characteristics, healthcare access and utilization, and potentially comorbid special healthcare conditions. Sociodemographic variables included child age, sex, race/ethnicity, maternal education level, family structure (two parent – adoptive or biological, two parent – step family, single mother – no father present, or other family type), and income based on federal poverty level (FPL). Healthcare access and utilization items assessed recent dental care (‘During the past 12 months, did [CHILD’S NAME] see a dentist for any kind of dental care, including checkups, dental cleanings, Xrays, or filling cavities?’). Health insurance coverage was determined by two questions: ‘Does [CHILD’S NAME] have any kind of healthcare coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid?’ and ‘If yes, is that coverage Medicaid or the Children’s Health Insurance Program, CHIP?’ Children who are insured but do not have public insurance were coded as having private insurance coverage. Children with special healthcare needs (CSHCN) are those who require prescription medications to manage their condition, need or use specialized services or therapies, and/or experience of one or more functional limitations. The CSHCN screener (28) used to identify these children in this sample included 19 items to assess these needs. Children were categorized as either having a special healthcare need based on one or more of the aforementioned criteria or not having a special heathcare need. Analyses Observations were weighted using complex sampling specifications provided in the NSCH dataset (27) with state and telephone phone type (cellular or landline) as stratum identifiers and unique household identifier as the primary sampling unit. Resulting estimates are representative of all noninstitutionalized children aged 0–17 years in the United States and in each state. All analyses were conducted using complex design techniques in SPSS version 22.0 (Armonk, NY, 2013). Univariate analyses were first conducted to determine the number of children with poor dental health. Next, bivariate analyses were conducted to test the association between number of ACEs and the two dental health outcomes. Finally, multivariate logistic regression analyses were conducted to determine the likelihood of (i) having teeth in fair or poor condition and (ii) having a toothache, decayed teeth, and/or unfilled cavities in the past 12 months. Two models for each outcome were tested, the first was unadjusted and included only ACEs, the second adjusted for sociodemographic characteristics, healthcare access and utilization, and potentially comorbid medical conditions for a total of 4 logistic regressions analyses. Results Sample characteristics Descriptive statistics for sample characteristics are outlined in Table 1. The average age of children was 8.59 years (Standard Error = 0.04). Approximately, 46% of parents rated their children’s teeth excellent, 26% very good, 21% good, 6% fair, and 2% poor. In these analyses, responses of fair and poor were combined to indicate poor dental health. A little over 18% of caregivers reported that their child had a toothache, decayed teeth, and/or unfilled cavities in the past 12 months. Most caregivers reported that their (73%) child visited a dentist within the previous 12 months (Table 1). In regards to ACEs, slightly more half (54%) of parents reported their children having no ACEs. 195 Bright et al. Table 1. Descriptive statistics of sample as reported by parents of children aged 1–17 years with natural teeth Variable Dental health and practices Condition of child’s teeth is fair/poor Had toothache, decayed teeth, and/ or unfilled cavities in past 12 months Visited a dentist in past 12 months Sex: Female Income 0–99% FPL 100–199%FPL 200–399% FPL 400%+ FPL Race/Ethnicity Hispanic Non-hispanic black Non-hispanic white Other Maternal education: less than high school diploma Family structure Two parent – biological or adoptive Two parent – step family Single mother – no father present Other family type Insurance coverage Private insurance Public insurance Uninsured Has special healthcare need Adverse childhood experiences Divorce of a parent Parent spent time in jail Exposure to domestic violence Witness to or victim of neighborhood violence Exposure to drug and alcohol abuse Lived with someone who was mentally ill, suicidal, depressed Hard to get by on family income Number of ACEs 0 adverse childhood experiences 1 adverse childhood experiences 2 adverse childhood experiences ≥3 adverse childhood experiences n % 4,858 14,736 7.6 18.7 72,777 43,853 73.1 48.8 13,901 16,247 27,545 32,862 22.4 21.5 28.2 27.8 11,469 8,446 58,244 9,810 6,250 23.0 13.7 53.0 10.4 14.3 62,079 6,534 14,389 6,460 65.6 8.8 19.0 6.7 60,034 25,516 3,922 19,458 57.4 37.1 5.6 19.8 16,967 5,572 5,861 8,410 20.1 6.9 7.3 8.6 9,941 8,410 10.7 8.6 18,870 25.7 54,392 20,924 7,948 8,591 54.4 25.2 9.9 10.5 Raw values are unweighted; percentages are weighted based on the specifications for complex samples FPL, federal poverty level. Approximately, a quarter (25%) of children had one ACE, while a tenth (10%) had two ACEs, and another tenth (10%) had three or more. Bivariate analyses A higher proportion of children experiencing any ACE had teeth in fair/poor condition compared to children who did not experience an ACE. The same was true for all ACEs and having a toothache, decayed teeth, and/or unfilled cavities. Similar patterns were found for number of ACEs. 196 Multivariate analyses Condition of teeth is fair or poor. There was a graded association between number of ACEs and likelihood of caregiver report of having teeth in fair or poor condition. Adjusting for sociodemographic characteristics, healthcare access, and healthcare utilization, children whose parents reported more than one ACE were 1.35–1.65 times more likely to have parent-reported teeth in fair or poor condition (Table 2). Toothache, decayed teeth, and/or unfilled cavities in past 12 months. Adjusting for sociodemographic characteristics, healthcare access, and utilization, children who experienced more than one ACE were 1.38–2.11 times like more likely to have parentreported teeth in fair or poor condition (Table 2). Discussion This study investigated (i) frequency of poor dental health in children and adolescence, (ii) the frequency of adverse childhood experiences for children with poor dental health, and (iii) the association between number of ACEs and poor dental health outcomes in children. Much of the literature on child/adolescent dental health outcomes identifies patterns of health equity (or inequity) that are similar to our findings including poorer health among racial and ethnic minority groups, children from lower socioeconomic families, and children without health insurance or access to health care (7–14). Our study contributes to the literature by adding specific risk factors of a child’s home life and related family dynamics in the form of adverse childhood events. Our findings indicate that children exposed to several ACEs are more likely to have poor dental health and more likely to have toothaches, decay, and/or unfilled teeth compared to children not exposed to these experiences. Another important finding in this study is the graded association between number of ACEs and likelihood of poor dental health outcomes. Having only one ACE was associated with a slight increase in likelihood of having poor dental health; the combination of three or more ACEs, however, more than doubled the likelihood. Several other studies have found similar results (29, 30) supporting the cumulative effects of adverse experiences on poor health and developmental outcomes. Adverse childhood experiences and pediatric dental health Table 2. Likelihood of having poor dental health based on adverse childhood experiences Variable Condition of teeth is fair or poor Toothache, decayed teeth, and/or unfilled cavities Unadjusted OR (CI) Number of ACEs 1 adverse childhood experiences 2 adverse childhood experiences ≥3 adverse childhood experiences 1.84 (1.56–2.17) 1.84 (1.52–2.24) 2.51 (2.09–3.00) 1.61 (1.45–1.78) 1.89 (1.65–2.15) 2.55 (2.25–2.89) Adjusted OR (CI) Number of ACEs 1 adverse childhood experiences 2 adverse childhood experiences ≥3 adverse childhood experiences Sociodemographic characteristics Age (continuous) Sex Female Income 0–99% FPL 100–199%FPL 200–399% FPL Race/Ethnicity Non-hispanic black Hispanic Other Maternal education Less than high school diploma Family structure Two parent – step family Single mother – no father present Other family type Healthcare access and utilization Visited a dentist in past 12 months Yes Insurance coverage Public insurance Uninsured Comorbid conditions Has special healthcare need 1.35 (1.13–1.62) 1.46 (1.15–1.85) 1.65 (1.30–2.10) 1.38 (1.23–1.55) 1.66 (1.41–1.95) 2.11 (1.78–2.50) 1.03 (1.01–1.05) 1.03 (1.02–1.04) 0.88 (.76–1.02) 1.06 (.97–1.16) 2.93 (2.13–4.05) 2.30 (1.74–3.06) 1.59 (1.25–2.03) 1.81 (1.51–2.16) 1.80 (1.55–2.10) 1.38 (1.23–1.56) 1.28 (1.04–1.58) 2.28 (1.92–2.69) 1.70 (1.36–2.13) 1.41 (1.23–1.61) 1.41 (1.24–1.60) 1.44 (1.24–1.66) 2.02 (1.67–2.43) 1.43 (1.23–1.66) 0.92 (0.73–1.16) 0.85 (0.70–1.03) 2.21 (0.71–6.92) 0.94 (0.80–1.10) 0.88 (0.77–1.00) 0.58 (0.29–1.14) 1.04 (0.86–1.25) 4.05 (3.47–4.72) 1.40 (1.21–1.75) 2.37 (1.79–3.14) 1.25 (1.10–1.43) 1.74 (1.38–2.18) 1.75 (1.49–2.06) 1.12 (1.01–1.24) FPL, federal poverty level; Referent groups: 0 adverse childhood experiences, male, 400+%FPL, non-Hispanic White, at least a high school diploma, two parent – biological or adoptive, did not visit a dentist in the past 12 months, private insurance, does not have special healthcare need. Potential mechanisms underlying the association between ACEs and dental health include both social and physiological factors. Social factors linking ACEs to poor dental health could include family routines and functioning and parental attitudes toward oral health. When family and/or caregiver functioning are low, it may be more difficult to establish behaviors related to preventive dental care (31). Moreover, families who experience financial hardship may have trouble with transportation to dental visits, covering co-payments, or purchasing toothpaste and toothbrushes. Physiologically, chronic stress, and subsequent activity of the neuroendocrine and immune systems, associated with socially disadvantaged families may be an underlying mechanism that may explain the prevalence of health concerns, including dental caries, in these children (32–34). Limitations The primary limitation of this study is the use of parent report for children’s dental health and adverse experiences. With regard to ACEs, parents may be unwilling to report that their child has experienced adversity or may be unaware of the occurrence of certain experiences (e.g., neighborhood violence). Parent report of oral health may also not be as accurate as an oral exam performed by a dentist or dental hygienist. In a recent study of parents and preschool children, however, researchers found parent reports of dental health status to be relatively accurate when compared to dental examination (35). 197 Bright et al. A second limitation is the cross-sectional design of this study and subsequent inability to infer causality in the association between adverse experiences and dental health. Based on models of toxic stress, we expected that adverse experiences increased the likelihood of poor dental health (16). It is also possible, however, that poor dental health in children creates additional strains in families and increases the likelihood of adverse experiences. Untangling these relationships will require additional studies with longitudinal design. Finally, we were unable to include questions regarding dental insurance specifically as it was not included in the NSCH survey. Given that children with dental insurance are more likely to have access to dental care and subsequently better oral health than children without dental insurance (14), it is possible that poor dental health in our sample was due at least in part to lack of dental insurance. Similarly, previous research on ACEs and other health outcomes has generally included measurement of various forms of child abuse and neglect (physical, emotional, sexual). Additionally, questions regarding child abuse and neglect were not included in the NSCH survey and thus were not available for the current analyses. Implications Given our findings that ACEs are associated with poor dental health, what can pediatric dentists do to address this in their practice? First, the American Academy of Pediatric Dentistry (AAPD) recommends a dental checkup at least twice a year for children beginning at age one and promotes guidelines on the components of a comprehensive checkup. These guidelines offer two components where ACEs could be assessed: general health/ growth and behavior of the child (36). Second, the AAPD has a caries risk-assessment form for children ages 0 to ≥6. The form includes biological, protective, and clinical findings that sort children into low, moderate, or high risk (37). Recommendations for high risk include recall every three months and more frequent radiographs. Future research should design and test whether ACEs can be assessed during a comprehensive dental visit using a standardized checklist. Conclusion This study further reinforces the research that states that we must recognize the health disparities that 198 arise from socioeconomic and racial differences. The complexity of these health outcomes, however, goes beyond these differences. As a burgeoning field of literature has begun to show, toxic stress plays a role in children’s health. What this study provides is strong evidence that dental health is just as susceptible to these adverse childhood experiences and while their effects are not uniform, their cumulative effects are nevertheless burdensome. The effect of toxic stress on dental health should remain in the foreground of dentists, public health advocates, and researchers. If screening for ACEs in dental visits can be improved, future research can focus on refining intervention plans and minimizing dental healthcare disparities. Acknowledgments The corresponding author (MB) had full access to all of the data under a data use agreement between CAHMI’s Data Resource Center and Melanie Sberna Hinojosa. The authors take responsibility for the integrity of the data and the accuracy of the data analysis. None of the authors have potential conflict of interests to declare. References 1. Sheiham A. Dental caries affects body weight, growth and quality of life in pre-school children. Br Dent J 2006;201:625–6. 2. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health 2011;101:1900–6. 3. Blumenshine SL, Vann WF Jr, Gizlice Z, Lee JY. Children’s school performance: impact of general and oral health. J Public Health Dent 2008;68:82–7. 4. Filstrup SL, Briskie D, da Fonseca FM, Lawrence L, Wandera A, Inglehart MR. Early childhood caries and quality of life: child and parent perspectives. Pediatr Dent 2003;25:431–40. 5. Center for Disease Control and Prevention. Hygienerelated Diseases: Dental Caries. Available at: http:// www.cdc.gov/healthywater/hygiene/disease/dental_caries.html [last accessed February 1, 2014] 6. Center for Disease Control and Prevention. Oral Health: Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers, at a glance 2011. Available at: http://www.cdc.gov/chronicdisease/resources/ publications/AAG/doh.htm. [last accessed February 1, 2014] 7. Flores G, Tomany-Korman SC. Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics 2008;121:e286–98. 8. Mouradian W, Wehr E, Crall J. Disparities in children’s oral health and access to dental care. JAMA 2000;284:2625–31. Adverse childhood experiences and pediatric dental health 9. Vargas CM, Ronzio CR. Disparities in early childhood caries. BMC Oral Health 2006;6(Suppl 1):S3. 10. Crall JJ, Edelstein B, Tinanoff N. Relationship of microbiological, social, and environmental variables to caries status in young children. Pediatr Dent 1990;12:233–6. 11. Newcheck PW, Hughes DC, Hung Y, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000;105:989–97. 12. Watson MR, Manski RJ, Macek MD. The impact of income on children’s and adolescents’ preventive dental visits. JADA 2001;132:1580–7. 13. Mofidi M, Slifkin R, Freeman V, Silberman P. The impact of a state children’s health insurance program on access to dental care. JADA 2002;133:707–13. 14. Lave JR, Keane C, Lin CJ, Ricci EM. The impact of dental benefits on the utilization of dental services by low-income children in western Pennsylvania. Pediatr Dent 2002;24:234–40. 15. Evans G. The environment of childhood poverty. Am Psychol 2004;59:77–92. 16. Johnson SB, Riley AW, Granger DA, Riis J. The science of early life toxic stress for pediatric practice and advocacy. Pediatrics 2013;131:319–27. 17. Chen E, Hanson MD, Paterson LQ, Griffin MJ, Walker HA, Miller GE. Socioeconomic status and inflammatory processes in childhood asthma: the role of psychological stress. J Allergy Clin Immunol Pract 2006;117:1014–20. 18. Chen E, Cohen S, Miller GE. How low socioeconomic status affects 2-year hormonal trajectories in children. Psychol Sci 2010;21:31–7. 19. Felitti V, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998;14:245–58. 20. Flaherty EG, Thompson R, Dubowitz H, Harvey EM, English DJ, Proctor LJ et al. Adverse childhood experiences and child health in early adolescence. JAMA Pediatr 2013;167:622–9. 21. Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, Dong M et al. Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. J Adolesc Health 2006;38:444 e1–10. 22. Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004;82:217–25. 23. Anda RF, Brown DW, Dube SR, Bremner JD, Felitti VJ, Giles WH. Adverse childhood experiences and chronic obstructive pulmonary disease in adults. Am J Prev Med 2008;34:396–403. 24. Chartier MJ, Walker JR, Naimark B. Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization. Child Abuse Negl 2010;34:454–64. 25. Chartier MJ, Walker JR, Naimark B. Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. Am J Public Health 2009;99:847– 54. 26. Flaherty EG, Thompson R, Litrownik AJ, Zolotor AJ, Dubowitz H, Runyan DK et al. Adverse childhood 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. exposures and reported child health at age 12. Acad Pediatr 2009;9:150–6. Centers for Disease Control and Prevention National Center for Health Statistics, State and Local Area Integrated Telephone Survey. 2011–2012 National Survey of Children’s Health Frequently Asked Questions. Available at: http://www.cdc.gov/nchs/slaits/nsch.htm. [last accessed March 1, 2013] Bramlett MD, Read D, Bethell C, Blumberg SJ. Differentiating subgroups of children with special health care needs by health status and complexity of health care needs. Matern Child Health J 2009;13: 151–63. Suliman S, Mkabile SG, Fincham DS, Ahmed R, Stein DJ, Seedat S. Cumulative effect of multiple trauma on symptoms of posttraumatic stress disorder, anxiety, and depression in adolescents. Compr Psychiatry 2009;50:121–7. Lloyd DA, Turner RJ. Cumulative lifetime adversities and alcohol dependence in adolescence and young adulthood. Drug Alcohol Depend 2008;93:217–26. Levin KA, Currie C. Adolescent toothbrushing and the home environment: sociodemographic factors, family relationships and mealtime routines and disorganisation. Community Dent Oral Epidemiol 2010;38:10–8. Marketon JIW, Glaser R. Stress hormones and immune function. Cell Immunol 2008;252:16–26. Pani SC, Abuthuraya D, Alshammery HM, Alshammery D, Alshehri H. Salivary cortisol as a biomarker to explore the role of maternal stress in early childhood caries. Int J Dent 2013;2013:565102. Boyce WT, Den Besten PK, Stamperdahl J, Zhan L, Jiang Y, Adler NE et al. Social inequalities in childhood dental caries: the convergent roles of stress, bacteria and disadvantage. Soc Sci Med 2010;71:1644–52. Talekar BS, Rozier G, Slade GD, Ennet ST. Parental perceptions of their preschool-aged children’s oral health. JADA 2005;136:364–72. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent 2013;35:E148–56. American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35:E157–64. Supporting Information Additional Supporting Information may be found in the online version of this article: Appendix S1. Percentage of children with fair/poor condition of teeth based on number of adverse childhood experiences. Appendix S2. Percentage of children with a toothache, decayed teeth, and/or unfilled cavities in the past 12 months based on number of adverse childhood experiences. Appendix S3. Description of items measuring adverse childhood experiences 199
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