Can parental pain catastrophizing influence the relationship between dental caries and pain in early childhood?

Introduction

Pain and related factors assessment are mandatory in health care; however, it is challenging when a self-report approach is not possible, as occurs when studying early childhood conditions. There are three main ways to assess pain intensity in children: physiological, behavioral, and self-report [1]. Although self-report measures are preferable for obtaining information about childhood pain, they are limited to children who can communicate and understand what they feel [1].The parents’ report about their child’s pain can be a reliable measure in diagnosing pain in early childhood [1, 2]; still, responses can be influenced by the adults’ personality and emotional characteristics [3] such as pain catastrophizing [4].

Studies on how parental pain catastrophizing can influence the pain responses of their children have been developed. Pain catastrophizing refers to a set of negative and exaggerated cognitions and emotions through a condition of actual or future pain [5]. Parents who catastrophize about their children’s pain may experience emotional reactions [6], showing to be more anxious and distressed than those who do not have catastrophic thoughts about their children’s pain [7]. This situation can lead to adverse effects in children, such as increased pain intensity [8, 9], pain catastrophizing by the child [10, 11], and increased pain behavior (perceived by parents) [12].

Pain in the mouth (mainly dental) is a condition that affects approximately one in seven young children globally and negatively impacts their wellbeing [13, 14]. Parents report dental pain in their young children by observing their daily activities (e.g., negative behaviors when eating or sleeping) [15]. In early childhood, dental caries is reported as the leading cause of toothache [16, 17, 18]. When the child’s dental pain is not managed, psychological, physical, and social damage can be generated, having a substantial negative impact on these children’s and family’s daily lives [19, 20, 21].

Adults describe their toothaches as the worst feelings ever felt [22], being more intense than earaches or headaches and comparable to backaches [23]. When mothers perceive pain in their children, they remember their past suffering and seek help [24]. One study revealed that young children’s toothache at night is associated with parental catastrophizing [25]. However, whether children’s pain catastrophizing by parents impacts the direct effect of children’s caries experience on parental pain reports remains unclear. The present study aimed to verify if parental catastrophizing of their children’s pain influences the relationship between dental caries and perceived dental pain in early childhood and, further, whether the child’s age interacts with this relationship.

MATERIALS AND METHODS

Statistical analysis

The statistical tests were performed with the IBM SPSS Statistics for Macintosh Version 24.0 (IBM Corp., Armonk, NY, United States) with the PROCESS macro for the moderation and mediation analyses [29]; the significance value was set to p $<$ 0.05 (95% confidence intervals).

The Kolmogorov-Smirnov test was used to verify the normality of the quantitative variables and define their description as mean and standard deviation (SD) or median and quartiles one (Q1) and three (Q3), as well as the bivariate tests to test their relationships. Frequencies (n) and percentages (%) were calculated for the description of children’s sex.

We ran the Spearman correlation test to calculate correlations between the variables—children’s age, caries experience (dmft), pain intensity (DDQ-B)—and pain catastrophizing by parents (PCS-P). The correlation coefficients were considered weak (between 0.1 and 0.2), moderate (between 0.3 and 0.6), and strong (between 0.7 and 0.9).

To test how parental catastrophizing of their children’s pain mediates the effect of caries experience on dental pain report, we used PROCESS (v. 3.4, model 4) and performed a simple mediation model with 5000 bootstrap samples and applied a confidence interval of 95% [29]. Caries experience (dmft) was added as the predictor, dental pain intensity (DDQ-B) as the outcome, and parental catastrophizing (PCS-P) as the mediator (Fig. 1).

Fig. 1.Diagrams of the simple mediation model. Fig. 1A: Conceptual diagram testing if parental catastrophizing of their children’s pain influences the relationship of caries and pain intensity. Fig. 1B: Statistical diagram for the same model. Abbreviations: dmft—decayed, missing, and filled index for primary teeth; DDQ-B—Dental Discomfort Questionnaire, Brazilian version; PCS-P—pain catastrophizing scale by parents.

We also used the PROCESS (v. 3.4, model 15) to test whether children’s age interacts with the relation ‘parental catastrophizing and children’s dental caries and pain intensity’ [29]. A moderated mediation model (conditional process analysis) was performed with the same standards as above (5000 bootstrap samples, confidence interval of 95%) and adding the children’s age as the moderator to the previous mediation model (Fig. 2).

Fig. 2.Diagrams of the conditional process analysis. Fig. 2A: Conceptual diagram for testing if the children’s age could indirectly influence parental catastrophizing of children’s pain and directly influence the relationship of caries and pain intensity. Fig. 2B: Statistical diagrams of the same model. Abbreviations: dmft—decayed, missing, and filled index for primary teeth; DDQ-B—Dental Discomfort Questionnaire, Brazilian version; PCS-P—pain catastrophizing scale by parents.

RESULTS

Of the 84 children and their parents who participated in the original clinical trial, one dyad was excluded for not responding to the PCS-P. The descriptive data of the participants are shown in Table 1. Just over half of the children were male (50.6%), with a median age of 38.0 months (Q1 33.0, Q3 48.0), and most of the respondents were mothers (n = 73; 88.0%). We ran the following analysis for all respondents, as only mothers’ cases did not impact the final results reported herein. As most of them were parents, we hereafter use the noun ‘parents’ for clarity.

The children’s dmft mean was 8.5 (SD 3.9), and their parents reported a pain intensity (DDQ-B) with a median of 4.0 (Q1 3.0, Q3 8.0). Parental catastrophizing, as assessed through the PCS-P, had a mean of 36.6 (SD 9.3). Considering the cut-off point for the PCS-P, 80.7% (n = 67) of parents were catastrophizers about their children’s pain. DDQ-B presented significant correlations with PCS-P and dmft (Table 2). These variables did not associate with children’s sex (data not shown).

The results for the simple mediation model show that the direct effect of caries experience remained significant when statistically controlling for pain catastrophizing in the regression model (c = 0.22; p = 0.01). The parental pain catastrophizing was not a partial mediator for the relationship caries experience—pain intensity as the confidence interval crosses zero (a$\times$b = 0.05; lower level of the confidence interval: -0.01; upper level of the confidence interval: 0.14) (Table 3).

In the moderated mediation model, no effect was observed between age and the mediator or the outcome variables or between pain catastrophizing and age with the dental pain intensity (Table 4). Caries experience remained a predictor for the pain intensity and accounted for the total effect of the model. The model predicted that children who differed by one unit in caries experience were estimated to vary by 0.22 units in their pain intensity. These results indicate that children’s age did not moderate the direct or indirect (through catastrophizing) effect of caries on pain intensity.

DISCUSSION

This study sheds light on a relevant topic for the pediatric dentistry practice. There was a direct relationship between caries experience in early childhood and the child’s dental pain intensity report by parents. Although expected, this correlation was not influenced either by parental catastrophizing on their children’s pain or by the children’s age. Below, we interpret this result guided by the following principles: 1- dental pain has an acute nature; 2- the children’s age group was restricted to early childhood; 3- catastrophizing trait and state; 4- other dimensions of pain.

We proposed the present moderated-mediation model inspired by the study by Langer et al. [6] with 8–17-year-old children with inflammatory bowel disease. In that study, parental catastrophizing was a partial mediator for the association between parental report of child pain and their protective responses towards their child’s symptoms [6]. Children’s older age and their chronic disease may have led to mediation [6]. In the endodontic context, adults’ catastrophizing was associated with pain in interventions but not with pain reports in the first session [30]. Dental pain is an acute pain that requires immediate access to the dental office, as home ‘remedies’ do not solve the problem [24]. We could then hypothesize that parents with higher levels of catastrophic thinking did not have enough time to let their thoughts influence their perception of children’s pain.

However, when the bivariate analysis was performed, a positive correlation between parents’ catastrophic thoughts and their report of children’s dental pain intensity was found. Overall, most parents had catastrophic thoughts about their children’s pain. Nevertheless, we assessed parental pain catastrophizing as a personality trait and not a specific situational circumstance (state). A study with 8 to 12-year-old children during a cold pressor task and their parents [31] found a significant interaction between child and parent state pain catastrophizing in predicting child symptom complaints. Another study with adolescents (10 to 18 years) and parents examined the role of their pain catastrophizing to produce pain memories after surgery. The results showed that the respondents’ catastrophizing influenced the pain memory [32]. However, parents’ catastrophizing had a more prominent role in recognizing the adolescents’ pain by both children and parents [32]. The lack of evidence on the associations between young children’s and parents’ pain catastrophizing makes it challenging to compare our results.

Pre-schoolers have difficulties describing their pain, identifying why pain hurts, and attribute value to their pain, comparing with children six years and above [33]. As we included only children up to 6 years old in this study, we failed to demonstrate any significant relation between children’s age, their caries experience, and parents’ catastrophic thoughts and proxy dental pain report. Probably, these children displayed more intense symptoms of discomfort with the dental treatment itself (they were referred for sedation because they had a history of negative behavior in the dental chair) than with their cavities. Moreover, children can mask their pain signals because they fear the pain management (in this case, dental treatment) [34].

Anyway, children in our study had a high caries experience observed in the dental examination and a moderate pain level as reported by their parents. There was a weak to moderate correlation between caries experience and pain intensity, probably because of potentially chronic lesions that do not provoke pain. Likewise, higher DDQ-B scores were associated with a higher rate of caries experience [18]. On the other hand, a previous study [25], showed a relationship between catastrophic thoughts of parents and dental pain at night in children; however, the frequency of nocturnal dental pain was low in our investigation.

One of the strengths of this study is that a validated questionnaire was used to verify toothache in young Brazilian children. Although we used a bootstrapping method for the statistical estimates, one cannot deny the limited, albeit controlled, sample size. We included clinical participants, giving a more realistic context, but all children had caries, and most parents were catastrophizing and female. Additional research with larger samples and greater representativeness, including children without cavities, non-catastrophizing parents, and catastrophizing fathers, could eliminate potential biases.

All in all, this study highlights the need for researchers’ attention on the assessment of oral pain in children. Discoveries in this specific area may help elucidate more systemic aspects of pain management in children.

CONCLUSIONS

Catastrophizing children’s pain by the parents did not influence the direct relationship between caries experience and perceived toothache in early childhood. Also, the child’s age does not interact with this relationship.

FUNDING

This research received no external funding.

ACKNOWLEDGEMENT

The author LRC received research scholarship from the National Council for Scientific and Technological Development (‘Conselho Nacional de Desenvolvimento Científico e Tecnológico’, CNPq), Brazil.

DECLARATIONS OF INTEREST

None.