BMC Oral Health volume 25, Article number: 1079 (2025) Cite this article
Dental pain is a major public health concern, and analysing its prevalence and possible risk factors is important for effective treatment and prevention. This study explored the risk factors of dental pain among 12-year-old schoolchildren, with a focus on chain mediation analysis linking parents’ education to dental pain.
A cross-sectional study was conducted using data from surveys conducted in 2015 (769 schoolchildren) and 2024 (1090 schoolchildren). Participants underwent oral examinations and completed questionnaires assessing the epidemiological characteristics of dental pain and contributing factors.
Dental pain prevalence in 2015, 2024, and the combined sample for 2015 and 2024 was 52.3%, 50.8%, and 51.4%, respectively. Multivariate logistic analysis revealed the following: (1) In 2015, dental pain correlated with the frequency of consuming sugary drinks; dental caries; and evaluating one’s teeth and oral health; (2) In 2024, sex; parents’ educational background; frequency of consuming desserts, candies, and sugary drinks; dental caries; and self-evaluation of oral health, were significant factors; (3) In the combined sample for 2015 and 2024, sex; parents’ educational backgrounds; frequency of consuming desserts, candies, and sugary drinks; dental caries; and self-evaluation of oral health, were associated with dental pain. Furthermore, by analysing data from the combined sample for 2015 and 2024, chain mediating effects analysis showed that self-evaluation of oral health and frequency of consuming desserts and candies mediated the relationship between parents’ educational background and dental pain.
Dental pain prevalence among 12-year-old schoolchildren is alarmingly high, and our study provides direct evidence that parents’ educational background is associated with dental pain. This study provides a new perspective on preventing dental pain.
Dental pain refers to pain caused by a dental disease and is one of the most prevalent health issues in children and adolescents. Currently, it is a major reason individuals seek dental treatment [1]. Adolescence, particularly around the age of 12 years, is a crucial period for developing proper habits and establishing healthy practices. Parents of children who have experienced dental pain face higher workplace absenteeism, increased guilt, and expenditures [2, 3]. Considering its significant impact on quality of life, academic performance, and psychological health, dental pain is a major public health concern [4, 5]. Therefore, for effective treatment and prevention, it is important to analyse its prevalence and possible risk factors.
Recent studies have focused on the profound significance of dental pain. A meta-analysis of 70 studies involving 347,496 individuals revealed that the overall prevalence of toothache among children and adolescents is 36.2% [6]. As illustrated in Fig. 1, prevalence rates vary significantly by geographic region: Oceania (27.4%), Asia (42.7%), Africa (58.0%), Europe (35.0%), Latin America (32.0%), and Anglo-Saxon America (13.0%) [6].
Globally, dental caries are the most prevalent and consequential oral disease [7] and the leading cause of dental pain in adolescents [8,9,10]. Dental caries negatively affect the quality of life and impose social and economic burdens [11, 12]. According to the National Oral Health Survey, the prevalence of dental caries among 12-year-old schoolchildren in China was 45.8%, 28.9%, and 38.5% in 1995, 2005, and 2015, respectively [13, 14]. Liaoning Province, located in northeast China and the centre of politics, economy, and culture, reported a prevalence of 51.2% in 2015, which is markedly higher than that in China as a whole [13]. Demographic diversity, socioeconomic characteristics, oral health habits, and individual risk factors may influence variations in the prevalence of dental caries. Beyond dental caries, studies have reported that dental pain among adolescents may be influenced by oral health behaviours [15]. To the best of our knowledge, no relevant reports exist on dental pain prevalence and its contributing factors in Liaoning Province to date.
This study aimed to explore the epidemiology of dental pain and its related factors among schoolchildren in Liaoning Province, based on the Fourth National Oral Health Survey in 2015 and a new survey in 2024. The findings will provide strategies for assessing the disease burden and planning dental healthcare services.
Schoolchildren (12-year-olds) were selected from middle schools in Liaoning Province using a multistage stratified cluster sampling method. Furthermore, based on the population data obtained from the 2010 census conducted by the National Bureau of Statistics of the People’s Republic of China, four cities (Urban: Shenyang and Jinzhou; Rural: Donggang and Zhuanghe) were selected in 2015, yielding a sample size of 769 [13]. In the 2024 survey, five new cities were included based on the original four cities. Finally, nine cities (Urban: Shenyang, Jinzhou, Anshan, and Chaoyang; Rural: Dandong, Zhuanghe, Benxi, Fushun, and Tieling) were selected in 2024. The regional distribution is presented in Fig. 2.
The sample size was calculated based on the fourth National Oral Health Survey in 2015 [16], which reported a 51.2% prevalence of dental caries among patients aged 12 years. The design effect (def = 4.5), significance level (α = 5%), margin of error (δ = 10%), and non-response rate (20%) were also included in the following formula:
$$n = deff\frac{{u\alpha /{2^2}}}{{{\delta ^2}}}p(1 - p)$$
Based on this estimation, the minimum required sample size for the 12-year-old schoolchildren in this study was 540. Oral examinations and questionnaires were administered after informed consent was obtained.
Oral clinical examinations were conducted at schools using plane mouth mirrors and community periodontal index probes under artificial light. Dental caries, gingival bleeding, and dental calculus were examined and diagnosed in all permanent teeth according to World Health Organisation (WHO) criteria [17].
Three examiners who had attended training programs and passed theoretical and practical training for the Fourth National Oral Health Survey in China ensured the reliability of the results. Data reliability was determined using kappa values. The kappa value for dental caries was required to exceed 0.8, while that for periodontal-related examinations was required to exceed 0.6. Trained interviewers instructed the children to complete the questionnaire in classrooms. Three questionnaire interviewers who had undergone national screening, training, and certification collected questionnaire information efficiently and in an unbiased manner. The questionnaire covered questions on demographic characteristics (age, sex, ethnicity, and registered residence), socioeconomic status (parental education and siblings), oral hygiene behaviours, and oral health awareness and attitudes. The variables pertaining to dental pain and associated factors are presented in Table 1.
Data analyses were performed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, NY, USA). The prevalence of dental pain in the schoolchildren N (%), was calculated. χ2 tests were used to compare proportions. Multivariate regression analysis was performed to investigate the influence of independent variables (sex, nationality, registered residence, siblings, parent’s educational background, information on oral examinations, oral health behaviours, sweet consumption, oral health awareness, and attitudes) on dental pain experiences. Statistical significance was set at p < 0.05. Using SPSS and the PROCESS 4.0 macro, Model 6 was selected, and the number of bootstrap samples was set to 5,000. A significant mediating effect was indicated if the 95% CI did not include zero. Simultaneously, the estimated values of the direct, indirect, and total effects were reported to comprehensively illustrate the pathway of the mediating effect. For the moderating effect, the significance of the interaction term between independent and moderating variables was first tested to determine whether a moderating effect existed. A significant interaction term indicated that the moderating variable had a significant moderating effect on the relationship between the independent and dependent variables. Further analysis involved conducting a simple slope analysis and plotting a moderating effect graph to visually demonstrate the impact of the independent variable on the dependent variable at different levels of the moderating variable.
This study comprised 1,859 12-year-old schoolchildren, all of whom underwent clinical examinations and completed the questionnaire, resulting in a 100% response rate. Of these, 769 schoolchildren from four cities participated in the survey in 2015, 56.4% of whom resided in urban regions. In 2024, 1090 adolescents from eight cities participated in the survey, and 44.2% of them resided in urban regions. Detailed demographic data are presented in Table 2.
Dental pain prevalence among schoolchildren decreased from 52.3% in 2015 to 50.8% in 2024 (Table 3). In 2015, no significant differences were observed in dental pain prevalence based on sex, nationality, registered residence, parents’ educational background, or siblings. However, by 2024, dental pain prevalence differed significantly, based on sex and parents’ educational background: it was more common in females (58.1%) than males (43.6%), and in children whose parents had lower educational backgrounds (55%) than in those whose parents had higher educational backgrounds (35.9%). The overall prevalence of dental pain in the total sample for 2015 and 2024 was 51.4%. Across the total sample, dental pain prevalence differed significantly, based on sex and parents’ educational background: it was significantly higher in females (56.5%) than in males (46.3%), and higher in children of parents with low educational background (55.5%) than in those with parents of high educational background (41.2%).
The influence of dental pain on the participating schoolchildren is summarised in Table 4. The proportion of schoolchildren who received pit and fissure sealants increased from 2015 to 2024 (19.1–20.9% and 57–58%, respectively). Conversely, the proportion of schoolchildren with dental trauma, gingival bleeding, and dental calculus decreased from 2015 to 2024 (13.7–12%, 77.2–34.2%, and 43.1–34.9%, respectively).
Dental pain was associated with dental caries in 2015, 2024, and the total sample for 2015 and 2024. The prevalence of dental pain in 2015, 2024, and the total sample for 2015 and 2024 was significantly higher in schoolchildren with dental caries (57%, 58%, and 57.6%, respectively) than in those without (47.3%, 39.1%, and 43%, respectively). However, dental pain was not significantly associated with pit and fissure sealants, dental trauma, gingival bleeding, or dental calculus in 2015, 2024, or the total sample for 2015 and 2024.
The questionnaire responses and survey completion rates were 100%. The prevalence of dental pain was based on various influencing factors, as presented in Table 5. In 2015, dental pain prevalence was significantly associated with the frequency of consuming desserts, candies (64.6%), and sugary drinks (71.4%). Schoolchildren who consumed these more than two times a day experienced significantly higher dental pain rates than those with lower intake frequencies (P = 0.019; P = 0.032).
By 2024, the frequency of carbonated drink consumption became a new influencing factor. Dental pain prevalence was significantly associated with the frequency of consuming desserts and candies (64.7%), carbonated drinks (51.8%), and sugary drinks (66.1%). Schoolchildren who consumed these more than two times a day had significantly higher dental pain rates than those with lower intake frequency (P < 0.001; P = 0.001; and P < 0.001, respectively). The factors influencing dental pain in the total sample for 2015 and 2024 were consistent with those of 2024 (P < 0.001; P = 0.019; P < 0.001).
As shown in Fig. 3, the main reason schoolchildren sought dental care in 2015 was dental pain. However, by 2024, the main reason schoolchildren sought dental care shifted to preventive and oral healthcare, followed by dental pain.
Reasons for schoolchildren visiting dental care institutions in 2015 and 2024
A: Consultation/Seeking advice; B: Preventive care; C: Emergency treatment for oral pain and other related conditions; D: Non-emergency treatment; E: I do not know/do not remember
The prevalence of dental pain based on oral health knowledge and attitudes according to the questionnaire is presented in Table 6. Dental pain prevalence was significantly associated with the self-evaluation of oral health in 2015 (P < 0.001), 2024 (P < 0.001), and the total sample for 2015 and 2024 (P < 0.001). Schoolchildren who evaluated their teeth as ‘excellent’ had lower dental pain prevalence.
To determine the factors influencing dental pain prevalence, the relevant data from 2015, 2024, and the total sample for 2015 and 2024 were analysed, and the results are presented in Table 7. In 2015, the frequency of consuming sugary drinks, dental caries, and the self-evaluation of oral health were associated with dental pain. The results are summarised as follows: consuming desserts and candies more than two times a week compared to less than two times a day (odds ratio [OR] = 1.380; 95% confidence interval [CI] = 1.099–1.888); schoolchildren with dental caries compared to those without (OR = 1.347; 95% CI = 1.005–1.806); self-evaluation of oral health as ‘good’ compared to ‘excellent’ (OR = 2.270; 95% CI = 1.302–3.957); and self-evaluation of oral health as ‘bad’ compared to ‘excellent’ (OR = 5.077; 95% CI = 2.535–10.169).
In 2024, sex, parents’ educational background, frequency of consuming desserts and candies, frequency of consuming sugary drinks, dental caries, and self-evaluation of oral health were associated with dental pain. Females, compared to males (OR = 1.609; 95% CI = 1.248–2.075); children of parents with a median educational background compared to those whose parents had a high educational background (OR = 1.648; 95% CI = 1.091–2.490); children of parents with a low educational background compared to those of parents with high educational background (OR = 1737; 95% CI = 1.245–2.424); those who consumed desserts and candies more than two times a day, compared to less than two times a week (OR = 1.925; 95% CI = 1.181–3.137); consumed sugary drinks more than two times a day, compared to less than two times a week (OR = 2.089; 95% CI = 1.036–4.212); schoolchildren with dental caries compared to those without (OR = 1.685; 95% CI = 1.292–2.197); those who evaluated their oral health as ‘good’ compared to ‘excellent’ (OR = 2.751; 95% CI = 1.539–4.918); and those who evaluated their oral health as ‘bad’ compared to ‘excellent’ (OR = 4.338; 95% CI = 2.227–8.447), were likely to experience more dental pain.
In the total sample for 2015 and 2024, sex, parents’ educational background, frequency of consuming desserts and candies, frequency of consuming sugary drinks, dental caries, and evaluation of one’s teeth and oral health were associated with dental pain. Females, compared to males (OR = 1.378; 95% CI = 1.137–1.67); children of parents’ with a low educational background compared to those of parents with high educational background (OR = 1.527; 95% CI = 1.200–1.944); those who consumed desserts and candies more than two times a week compared to less than two times a week (OR = 1.374; 95% CI = 1.110–1.702)); those who consumed desserts and candies more than two times a day compared to less than two times a week (OR = 1.833; 95% CI = 1.259–2.670); those who consumed sugary drinks more than two times a day compared to less than two times a week (OR = 2.155; 95% CI = 1.307–3.551); those with dental caries compared to those without (OR = 1.493; 95% CI = 1.228–1.816); those who evaluated their oral health as ‘good’ compared to ‘excellent’ (OR = 2.446; 95% CI = 1.637–3.655); and those who evaluated their oral health as ‘bad’ compared to ‘excellent’ (OR = 4.476; 95% CI = 2.782–7.201), were likely to experience more dental pain.
Chain mediation model of parent’s educational background and dental pain
The mediating effects analysis using data from the total sample for 2015 and 2024 showed that evaluating one’s teeth and oral health, as well as the frequency of consuming desserts and candies, mediated the relationship between parents’ educational background and dental pain. As shown in Fig. 4, in Eq. 1, parents’ educational background positively affected the self-evaluation of oral health (b = 0.055, P < 0.001) and negatively influenced the frequency of consuming desserts and candies (b = -0.039, P < 0.05). In Eq. 2, self-evaluation of oral health negatively influenced dental pain (b = -0.762, P < 0.001), while the frequency of consuming desserts and candies positively influenced dental pain (b = 0.371, P < 0.001). In Eq. 3, evaluating one’s teeth and oral health negatively influenced the frequency of consuming desserts and candies (b = -0.159, P < 0.001). In Eq. 4, parents’ educational background negatively influenced dental pain (b = -0.229, P < 0.001).
Chain mediation model of parents’ educational background and dental pain. PEB: Parents’ educational background, ETH: Evaluating one’s teeth and oral health, DC: Desserts and candies, DP: Dental pain. * P < 0.05, ** P < 0.01, and *** P < 0.001
Specifically, parents’ educational background influenced dental pain through the following four pathways: (a) parents’ educational background → self-evaluation of oral health → dental pain; (b) parents’ educational background → frequency of consuming desserts and candies → dental pain; (c) parents’ educational background → self-evaluation of oral health → frequency of consuming desserts and candies → dental pain; and (d) parents’ educational background → dental pain.
The total, direct, and indirect chain-mediating effects were calculated, as presented in Table 8. The results showed that the direct effect (-0.229) accounted for 79.5% of the total effect. The total indirect effect (-0.059) accounted for 20.5% of the total effect, indicating that 20.5% of the effect of parents’ educational background on dental pain occurred through three mediating effects; mediating effects (a), (b), and (c), represented 14.6%, 4.9%, and 1.0% of the total effect, respectively. Additionally, the above tests of the total, direct, indirect, and mediating effects of (a), (b), and (c) were statistically significant at a 95% CI with no overlap with zero.
To the best of our knowledge, this is the first study to report on the epidemiology of dental pain and its influencing factors in Liaoning Province, using data from the National Oral Health Survey in China, providing insights for oral health policies and health service planning. Our findings indicate that approximately half of the 12-year-old schoolchildren experienced dental pain (52.3%, 50.8%, and 51.4% in 2015, 2024, and the total sample for 2015 and 2024, respectively), which was higher than the overall prevalence of dental pain (36.2%) [6]. These results demonstrate that treatment and preventive interventions should be performed to improve the oral status of these children. Consequently, we further analysed the influencing factors and dental visits.
Sex and parents’ educational background, which emerged as new influencing factors in 2024 compared to 2015, were significantly associated with dental pain in 2015 and the total sample for 2015 and 2024. Multivariate logistic regression analysis showed that parents’ higher educational backgrounds had a protective effect against dental pain. The risk of dental pain in children whose parents had a low educational background was 1.737 times that in those with parents of a high educational background, which is consistent with that of a survey on dental pain in preschool children, where children of parents with lower education level had a higher prevalence of dental pain or discomfort [18]. Socioeconomic status is a multidimensional, comprehensive indicator that frequently includes parents’ educational background, occupational status, and household income, among others [19, 20]. In this study, considering that 12-year-old schoolchildren completed the questionnaires, the issues of household income may not have been answered accurately. Finally, parents’ education background was selected as the indicator for socioeconomic status. Family education is the primary approach to developing good oral hygiene habits in adolescents. Our previous study found that parents’ educational background was a factor in dental caries, with girls being more affected than boys [13]. This sex disparity may be explained by the greater prevalence of dental caries among females. Additionally, it has been reported that girls’ permanent teeth erupt earlier than boys’, increasing their exposure to sweets earlier and raising their risk of decay, suggesting that more attention should be paid to girls [21]. According to the WHO, dental caries is the fourth most common chronic disease requiring treatment [22]. Multivariate logistic regression analysis confirmed that dental caries was a risk factor for dental pain, and the risk of dental caries was 1.347, 1.685, and 1.493 times higher in 2015, 2024, and the total sample for 2015 and 2024, respectively. No significant associations were noted between dental pain prevalence and pit and fissure sealants, dental trauma, gingival bleeding, and dental calculus. However, untreated dental caries in children can lead to dental pain and affect daily activities, including sleep, eating, and school performance [23].
Although other demographic factors (nationality, registered residence, and siblings) were not significant, adolescents who lived in urban areas, with siblings, and in proximity to other nationalities, had higher dental pain prevalence than those who lived in rural areas, had no siblings, and were of Han nationality. A previous study found that dental pain was related to nationality and residential area [24] because of differences in basic medical care and oral health services [25]. The causes of dental pain were complex, involving biological factors including dental caries, dental trauma, and periodontal diseases and social behaviours such as oral health and medical behaviours [26, 27]. Studies have reported a close relationship between dental pain and certain factors, such as access to oral health services, as well as dental anxiety and fear. Children who experienced dental pain had higher levels of dental anxiety than those who did not [28, 29]. We also found that consuming desserts and candies, carbonated drinks, and sugary drinks was associated with dental pain prevalence. Multivariate logistic regression analysis confirmed that the frequent intake of sugary drinks, desserts, and candies was a risk factor for dental pain.
This study uniquely illustrates the chain mediating effect of the frequency of consuming desserts and candies, and the self-evaluation of oral health in the relationship between parents’ educational background and dental pain. The total indirect mediating effect was 20.5%, underscoring the critical influence of the mediators (consuming desserts and candies and the self-evaluation of oral health) on the relationship between parents’ educational background and dental pain. Specifically, high parents’ educational background levels were associated with better self-evaluation of oral health, reducing the likelihood of dental pain. Parents with higher education levels are generally more aware of the importance of oral health and are better equipped to assess their own and their children’s oral health status. This enhanced self-assessment capability facilitates the early detection of oral health issues, reducing the incidence of toothache. Research has indicated that parents’ educational levels are positively correlated with their ability to comprehend and utilise health information, which further influences the degree of attention they pay to oral health [30, 31].
Moreover, high levels of parental education are associated with a lower frequency of consuming sugary foods, which also reduces the occurrence of dental pain. Parents with higher educational levels typically possess greater health literacy, enabling them to influence their children’s dietary habits through behavioural modelling and shaping the home environment. They are better equipped to understand the adverse effects of sugary foods on dental health and are more conscious of regulating their children’s dietary behaviours, thereby reducing the consumption of sugar-containing foods [32, 33]. Additionally, parents’ educational backgrounds promote oral health self-evaluation, leading to the selection of healthier foods and further reducing the risk of dental pain. Although the effect is small, its significance indicates that parents’ educational background can indirectly reduce dental pain by increasing oral health evaluation levels. This, in turn, ultimately lowers the risk of dental pain and forms a progressive mechanism of ‘cognition-behaviour-health’.
Notably, the primary reason for dental visits in 2024 was for prevention rather than for dental pain observed in 2015, reflecting increased parental emphasis on oral health. However, critical measures should be taken because of the high prevalence of dental pain. We should pay more attention to the oral health of rural adolescents and increase medical investments in developing areas. Additionally, oral health awareness and management measures should be improved. According to the Fourth National Oral Health Survey Report, only 11% of 12-year-old schoolchildren studied oral health-related courses [34]. Therefore, the government should popularise oral health-related courses in schools and establish an oral health management mode for families.
The main strength of the study lies in the use of provincial-level data from the central region of Northeast China to ensure data validity, and the use of a cross-sectional study to compare the differences and influences on dental pain over 10 years. Another significant strength is the chain mediating effects analysis used and the innovative proposal of a new chain mechanism of dental pain.
However, this study had some limitations. First, the presence of dental pain relied mainly on self-reports, introducing possible recall biases. Future research should incorporate objective measures (e.g., direct observation of oral hygiene practices) to validate self-reported data. Moreover, increasing the frequency of questionnaires and shortening the recording time may help reduce reporting bias. Then, this study included relatively few clinical oral examination indicators related to dental pain, which may lead to the omission of other relevant causative factors. Finally, a cohort study design with follow-up assessments may provide insights into how oral health behaviour influences dental pain over time and verify the causal relationship.
This study explored the epidemiology of dental pain and its related factors among schoolchildren in Liaoning Province. Our data suggested that parents’ educational background directly mediated dental pain and self-evaluation of oral health, while the frequency of consuming desserts and candies had an indirect mediating effect. These mediating effects may provide crucial insights for developing targeted interventions to mitigate the oral health burden and inform the optimisation of pediatric dental care services.
The data that supports the findings of this study are available from the corresponding author upon reasonable request.
- WHO:
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World Health Organisation
We sincerely thank all the schoolchildren and the guardians for their participation.
This work was supported by the Liaoning Provincial Natural Science Foundation of China (No. 2023-MS-158) and the Scientific Research Funding Project of the Education Department of Liaoning Province (LJKZ0784).
Approval for this study was obtained in accordance with the Declaration of Helsinki from the Stomatological Ethical Committee of the Chinese Stomatological Association (approval number: 2014-003) in 2015 and by the Ethics Committee of the School of Stomatology, China Medical University (approval number: K2024024).
Written informed consent was obtained from the participants before administering oral examinations and questionnaires. All data published here are under the consent for publication.
The authors declare no competing interests.
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Li, J., Lei, S., Zhang, S. et al. A chain mediation analysis of the association between parents’ educational background and dental pain among 12-year-old schoolchildren in Northeast China. BMC Oral Health 25, 1079 (2025). https://doi.org/10.1186/s12903-025-06475-4
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DOI: https://doi.org/10.1186/s12903-025-06475-4