A U.S. study of 44,489 children, published online September 29, 2026 in the Journal of Public Health Dentistry, found that children exposed to four or more adverse childhood experiences (ACEs) had 60% higher adjusted odds of caregiver-reported tooth decay. The same exposure was not linked to fewer preventive dental visits once income, insurance and other factors were accounted for. The authors stress that the cross-sectional design cannot show that adversity causes decay.
Childhood adversity has entered the dental caries conversation with a large national dataset behind it. As of October 2026, the study by Crouch and colleagues offers a fresh look at how cumulative ACEs relate to children's oral health in the period after COVID-19. For dental professionals in Toronto, the GTA and the rest of Canada, the findings raise a practical question: when a child presents with decay despite regular recall visits, what else might be going on at home?
This article summarizes what the paper reports, what it does not claim, and how Canadian practices can think about the results.
What did the study examine?
According to the paper's abstract, the researchers set out to assess the association between cumulative ACEs and two outcomes among U.S. children and adolescents: receipt of a preventive dental visit in the past year, and parent-reported tooth decay.
- Data source: the nationally representative 2022–2023 National Survey of Children's Health (NSCH), a U.S. survey.
- Design: cross-sectional.
- Sample: 44,489 children aged 6 to 17 with complete geographic data.
- Analysis: multivariable logistic regression, adjusted for sociodemographic, household and health-related factors, including language, income, insurance type, special healthcare needs and rural residence.
The authors are affiliated with the University of South Carolina Rural Health Research Center, the Division of Population Oral Health at the Medical University of South Carolina, and the University of North Carolina at Chapel Hill School of Dentistry.
What did the researchers find?
The headline result: children exposed to four or more ACEs had significantly higher odds of tooth decay than those with fewer than four, with an adjusted odds ratio of 1.60 (95% confidence interval 1.33 to 1.94). Oral Health Group described this as 60% higher adjusted odds.
The second finding is the one that deserves more attention in a recall-driven practice. After adjustment, cumulative ACE exposure was not associated with reduced receipt of preventive dental care. In other words, the data did not show high-adversity children missing more check-ups. The authors write that preventive dental care use may instead be influenced by broader socioeconomic and contextual factors.
The paper also lists other predictors of tooth decay in the models:
- low household income
- public insurance
- special healthcare needs
- speaking a language other than English at home
- rural residence
According to the abstract, children with high ACE exposure continued to show disproportionate oral health burdens.
What the study does not show
The authors are direct about the limits. The design is cross-sectional, and the study relies on caregiver-reported measures. They call for longitudinal studies to clarify the timing of exposure and outcome and to understand the pathways that might link childhood adversity and oral health. Oral Health Group's report adds that the design cannot establish that childhood adversity caused tooth decay.
Two further cautions for Canadian readers:
- It is U.S. data. Insurance categories such as "public insurance" reflect the U.S. system. They do not map directly onto Canadian programs.
- The full text is not open access. This summary is based on the published abstract and its indexing record. Specific ACE items, effect sizes for the other predictors and the full adjustment set are in the paper itself.
Pro Tip: Before citing this study in a team meeting or a patient handout, read the full paper through your university library or professional association access. The abstract gives you the headline numbers, not the measurement details.
Is there Canadian data on childhood adversity?
Canadian researchers noted in 2021 that population-level prevalence estimates for a broad range of ACEs were unavailable in Canada. That statement comes from a study in CMAJ Open by Joshi and colleagues. To help fill that gap, the team analyzed the first follow-up (2015–2018) of the Canadian Longitudinal Study on Aging, covering community-dwelling adults aged 45 to 85 in the 10 provinces, who reported their childhood experiences retrospectively.
Of 44,817 participants, 61.6% (weighted) reported exposure to at least one ACE. Physical abuse (25.7%), intimate partner violence (22.4%) and emotional abuse (21.8%) were the most common types reported. The authors concluded that the high prevalence underlines the need to develop and promote trauma-informed care.
That Canadian study looked at older adults recalling their childhoods, not at children's teeth, so its numbers cannot be compared with the U.S. dental findings. What it does show is that childhood adversity was common among Canadian adults aged 45 to 85, a group that includes many of your adult patients.
What does this mean for Canadian dental practices?
None of what follows comes from the study itself. It is general practice reasoning for clinicians who want to act on the findings carefully.
Rethink the "non-compliant family" label
If, after adjustment, high ACE exposure was not associated with fewer preventive visits but was associated with more reported decay, then attendance alone is not the full story. A child who keeps their recall appointments but keeps developing new lesions may be dealing with stressors at home that a brushing demonstration will not fix. Framing the conversation around support rather than blame keeps families coming back.
Consider trauma-informed approaches
Trauma-informed care, the approach the CMAJ Open authors recommend developing, generally means assuming that some patients carry difficult histories and adjusting how care is delivered: explaining each step before it happens, offering choices, and paying attention to signs of distress in the chair. These are communication habits, not a new clinical protocol, and they cost little to adopt across a pediatric schedule in North York, Brampton or anywhere else.
Pro Tip: Add one 30-minute team huddle this quarter on chairside communication for anxious or distressed children and caregivers. Assign one hygienist to bring two real (de-identified) scenarios from your own schedule.
Know your reporting obligations
The study's abstract does not address whether dental teams should screen for ACEs, and nothing here suggests that you should start doing so. What every Ontario practice should already know is its legal duty when abuse or neglect is suspected. The Royal College of Dental Surgeons of Ontario (RCDSO) states that Ontario's Child, Youth and Family Services Act requires health care professionals, including dentists, to promptly report to a children's aid society any suspicion that a child is or may be in need of protection. Make sure every team member knows where that guidance is and who in the practice handles a concern.
Look at the other risk factors on your own schedule
Income, special healthcare needs, home language and rural residence all appeared as predictors in the U.S. models. Canadian practices see versions of each: families who need appointments explained in another language, patients travelling in from rural Ontario, and children with complex medical needs. Interpreter support, longer appointment slots and clear written home-care instructions are practical, low-cost responses.
EBIKO Dental will continue monitoring research on social and family factors in pediatric oral health, including any longitudinal follow-up the authors recommend. More news for Canadian dental professionals is on the EBIKO Dental blog.
Sources
- Crouch E, Frattaroli N, Brian Z, Odahowski C, Martin A, Nelson J. Examining Adverse Childhood Experiences as a Risk Factor for Preventive Dental Care and Tooth Decay: National Survey of Children's Health 2022–2023. Journal of Public Health Dentistry, 2026. doi:10.1111/jphd.70083 (PMID 42808916)
- Joshi D, Raina P, Tonmyr L, MacMillan HL, Gonzalez A. Prevalence of adverse childhood experiences among individuals aged 45 to 85 years: a cross-sectional analysis of the Canadian Longitudinal Study on Aging. CMAJ Open 2021;9(1):E158–E166. doi:10.9778/cmajo.20200064
- Oral Health Group, "Large U.S. study links childhood adversity with poorer oral health," October 5, 2026
- RCDSO, Child Abuse and Neglect Protection
Frequently Asked Questions
Q: Do adverse childhood experiences cause tooth decay?
The evidence does not show that. The 2026 Journal of Public Health Dentistry study found an association: children with four or more ACEs had higher adjusted odds of caregiver-reported decay (aOR 1.60). Its authors say the cross-sectional design and caregiver-reported measures mean longitudinal studies are needed to clarify timing and pathways.
Q: Did children with more adversity miss more dental check-ups?
Not in this dataset, once other factors were accounted for. After adjustment, cumulative ACE exposure was not associated with reduced receipt of preventive dental care. The authors suggest preventive care use may be shaped by broader socioeconomic and contextual factors.
Q: How common are adverse childhood experiences in Canada?
As of 2021, researchers reported that population-level ACE prevalence estimates were unavailable in Canada. A 2021 CMAJ Open analysis of the Canadian Longitudinal Study on Aging found that 61.6% of participants aged 45 to 85 reported at least one ACE, with physical abuse, intimate partner violence and emotional abuse the most commonly reported.