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Background: Adverse childhood experiences (ACE) and bullying have negative effects on oral health. Promotive assets (resilience, self-esteem) and resources (perceived social support) can ameliorate their negative impact. The aim of this study was to determine the association between oral diseases (caries, caries complications and poor oral hygiene), ACE and bully victimization and the effect of access to promotive assets and resources on oral diseases. Methods: This was a secondary analysis of data collected through a cross-sectional school survey of children 6-16-years-old in Ile-Ife, Nigeria from October to December 2019. The outcome variables were caries, measured with the dmft/DMFT index; caries complications measured with the pufa/PUFA index; and poor oral hygiene measured with the oral hygiene index-simplified. The explanatory variables were ACE, bully victimization, resilience, self-esteem, and social support. Confounders were age, sex, and socioeconomic status. Association between the explanatory and outcome variables was determined with logistic regression. Results: Of the 1001 pupils with complete data, 81 (8.1%) had poor oral hygiene, 59 (5.9%) had caries and 6 (10.2%) of those with caries had complications. Also, 679 (67.8%) pupils had one or more ACE and 619 (62.1%) pupils had been bullied one or more times. The median (interquartile range [IQR]) for ACE was 1(3), for bully victimization was 1(5), and for self-esteem and social support scores were 22(5) and 64(34) respectively. The mean (standard deviation) score for resilience was 31(9). The two factors that were significantly associated with the presence of caries were self-esteem (AOR: 0.91; 95% CI: 0.85-0.98; p = 0.02) and social support (AOR: 0.98; 95% CI: 0.97-1,00; p = 0.02). No psychosocial factor was significantly associated with caries complications. Self-esteem was associated with poor oral hygiene (AOR: 1.09; 95% CI: 1.09-1.17; p = 0.03). Conclusion: There was a complex relationship between ACE, bully victimization, access to promotive assets and resources by children and adolescents, and oral health. ACE and bully victimization were not associated with oral health problems. Though self-esteem was associated with caries and poor oral hygiene, the relationships were inverse. Promotive assets and resources were not associated with caries complications though resources were associated with lower prevalence of caries.
Approval for the study was obtained from the Research and Ethics Committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria (ERC/2018/08/06). Permission was obtained from the Local Government Education Authority, Osun State, and the authorities of schools involved in this study. Informed consent for study participation was obtained from the parents of all eligible pupils enrolled in the study and assent was obtained from children 12–16 years old. The consent and assent forms were sent to parents ahead of the school-visit date. On the day of the visit, only children who had the filled and signed informed consent forms and, where appropriate, the assent forms were included in the study. When parents/guardians had not signed an informed consent form but the child was keen to participate in the study, the child’s parent(s)/guardian(s) were called by telephone to seek verbal consent, and a filled written consent was obtained retroactively. The phone conversation was recorded. If the parent/guardian showed no interest in child/ward participation, the child was excluded from the study. Data were collected anonymously. Students did not receive reimbursement for study participation. This is a secondary analysis of data collected to determine the association between caries and nutritional status. The primary study was a cross-sectional study that recruited children aged 6 to 16 years attending private and public primary and secondary schools in Ife Central Local Government Area, Ile-Ife, Osun State, Nigeria from October to December 2019. Children and adolescents with special health-care needs, those who were ill, and those who had fasted within a period of 3 months before data collection, were excluded from the study. The age 6-years was chosen as the lower limit because they would have developed the cognitive ability to respond to the questionnaire [49, 50]. The sample size for the primary study was determined according to the formula of Metcalfe [51] and using a caries prevalence of 13.9% as had been determined in a prior study in the population [52]. To recruit 168 children with dental caries, underweight, normal weight, overweight and obesity, 1209 children were required to give a power of 80%. The sample for the primary study was 1502. A multi-stage cluster sampling technique was used to recruit participants for the primary study. Children 6–10 years of age were recruited from primary schools, while those who were 11–16 years old were recruited from secondary schools. First, schools were stratified into primary and secondary schools. The ratio of primary to secondary schools in the study population was 2:1 and the ratio of public to private school was 1:4. Next, 20 primary schools (3 public, and 17 private) and 10 secondary schools (2 public and 8 private) were randomly selected. At the schools, the class registration list was used to identify classes with the highest number of children. Children from the selected classes were asked to pick ballot papers with ‘yes’ or ‘no’ options. Those who picked ‘yes’ were recruited for the study. An interviewer-administered questionnaire collected data on participant’s sex, age at last birthday (6–11-year-old and 12–16-year-old), and child’s socioeconomic status [53]. Other sections of the questionnaire are as follows: were measured according to the 10-item Adverse Childhood Experiences Questionnaire, which provides a measure of cumulative life stress experienced during childhood [54]. These include experiences of parental verbal or physical assault, parental divorce, witnessing of maternal or grandmother’s physical abuse, experiences of emotional deprivation, sexual assault, and/or having a family member who is an alcoholic, mentally ill or an ex-convict. The instrument has been validated for use in Nigeria [55]. The response to each of the 10 questions is either ‘yes’ or ‘no,’ with possible score ranges from 0 to 10. The higher the score the more life adversities the child has faced. was assessed with the victim subscale of the Illinois Bully Scale [56] and has been validated for use in Nigeria with a Cronbach’s alpha score of 0.78 [57]. The subscale consists of four questions that measure both physical and verbal victimization that individuals experience from or by peers. The responses to each question ranged from never (scored 0) to 1–2 times (1), 3–4 times (2), 5–6 times (3), and 7 or more times (4). The responses were summed to derived a total score which ranged from 0 to 16. was assessed with the 10-item Rosenberg’s self-esteem scale. Items are scored on a Likert-like scale with options ranging from “Strongly Disagree” (1 point), “Disagree” (2 points), “Agree” (3 points) to “Strongly Agree” (4 points). The scale has good psychometric properties [58] and has been validated for use among adolescents in Nigeria with a Cronbach’s alpha score of 0.88 [59]. Items 2, 5, 6, 8, 9 were reverse-scored and sum score was derived which ranged from 10 to 40 with higher scores indicating lower self-esteem. The continuous scores were used in analyses. was assessed with the 10-item Connor-Davidson resilience scale, which was validated for use in Nigeria with a Cronbach’s alpha score of 0.81 [60]. Each item is rated on a 5-point scale from 0 (‘not true at all’) to 4 (‘true nearly all the time’). The possible total score ranges from 0 to 40 with higher scores indicating higher resilience. was assessed with the 12-item multidimensional perceived social support scale [61, 62]. The scale has three subscales which inquired about an individual’s perception of the adequacy of support from family, friends, and significant-others’ family. Each subscale comprised four questions. Each item was rated on a 7-point Likert-type response format ranging from 1 – “very strongly agree” to 7- “very strongly disagree.” The possible total score ranged from 12 to 84 with higher total scores corresponding to higher levels of perceived social support, while lower scores indicated perceived unavailability or lack of social support [63]. The scale had been validated for use in Nigeria with a Cronbach’s alpha score of 0.78 [64]. Intra-oral examination assessed oral hygiene status using the Simplified Oral Hygiene Index [65]. The oral hygiene score ranges from 0 to 6 categorized into 0.0–1.2 indicating good oral hygiene; 1.3–3.0 as fair oral hygiene; and 3.1–6.0 as poor oral hygiene. The oral hygiene status was dichotomized into good (0.0–3.0) and poor (3.1–6.0) status for the logistic regression analysis. Intra-oral examination was also conducted according to the World Health Organization criteria of caries examination to determine the presence of decayed, missing teeth, and filled teeth due to caries using dmft /DMFT indices [66]. Caries status was determined after the oral hygiene status was assessed. Teeth were cleaned with gauze and examined under natural light with dental mirrors without probes. Children were examined seated on a chair. The dmft /DMFT indices were used to categorize the children’s caries status: dmft /DMFT =0 was categorized into caries absent while dmft /DMFT greater or equal to 1 was categorized as caries present. The proportion of children with and without caries was computed. The dmft /DMFT indices were also used to define the severity of caries for children with caries. Dmft /DMFT greater or equal to 3 was categorized as severe caries while dmft /DMFT scores of 0.1–2.99 was categorized as low caries severity, Complications associated with carious lesions were assessed with the pufa/PUFA index [67], which was computed for children who had caries. When the pufa/PUFA score was 0, the child was categorized as not having caries complications. Children with a pufa/PUFA score greater than 0 were categorized as having caries complications. Participants were examined seated on a chair in a private area, which was well illuminated with natural light, in the school compound in the presence of a school chaperone. Oral hygiene status was assessed after the questionnaire was filled. The examination was conducted by an examiner and recorded by the assistant. The examiner was calibrated on use of the dmft/DMFT and PUFA/pufa index. The examiner was first calibrated by a consultant and the inter-examiner reliability kappa score was 0.85. Next, an intra-examiner reliability (conducted 1 week after the first examination) was conducted with a kappa score of 0.90. The normal distribution of the explanatory variables (ACE, bully victimization, self-esteem, resilience, social support) was determined. The mean (SD) and median (Interquartile range – IOR) of the scores for the explanatory variables were computed. The association between the categorized outcome variables (caries, complications of caries, and poor oral hygiene) and age, sex, socioeconomic status was assessed using chi square test or Mann Whitney U test. The associations with the explanatory variables (ACE, bully victimization, self-esteem, resilience and social support) were determined using the Mann Whitney U test and Kruskal-Wallis test for the variables that were skewed and the t test for those that were normally distributed. Univariate and multivariable logistic regression was conducted to determine the crude and adjusted odds ratios. The models to determine the risk indicators for poor oral hygiene, caries, and complications of caries were adjusted for age, sex and socioeconomic status, which are factors associated with caries, oral hygiene status of children and ACE [68–70]. Statistical significance was conducted with Stata/SE 14.0 for Windows (2015) and measured as p < 0.05.
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