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Hair cortisol and cortisone provide integrated biomarkers of chronic HPA-axis activity, and their ratio reflects glucocorticoid metabolic balance and 11\u03b2-hydroxysteroid dehydrogenase activity, which may be influenced by chronic stress-related physiological dysregulation. The objective was to examine the association between hair cortisol, cortisone, and their ratio with dental caries prevalence and severity in adolescents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This secondary cross-sectional analysis included 550 adolescents aged 14\u201315 years from the Kazakhstan Adolescent Health Study. Dental caries was assessed using the DMFT index. Hair glucocorticoid concentrations were measured by liquid chromatography-mass spectrometry, log-transformed, and the cortisol-to-cortisone ratio (CCR) was standardized (z-score). Multivariable logistic regression estimated odds ratios across hierarchical models adjusting for sociodemographic, socioeconomic, and behavioral factors, with school region as a fixed effect and robust standard errors. Zero-inflated negative binomial (ZINB) models examined associations with caries count.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 550 participants, 84% had DMFT\u2009\u2265\u20091. Although unadjusted analyses did not show significant differences in CCR by caries status (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.079), higher standardized CCR was associated with increased odds of dental caries after multivariable adjustment (OR\u2009=\u20091.40, 95% CI: 1.04\u20131.89 per SD increase). Results were consistent across sensitivity analyses, including Firth\u2019s penalized logistic regression (OR\u2009=\u20091.36, 95% CI: 1.01\u20131.85). In ZINB analyses, CCR was not significantly associated with caries count. Individual glucocorticoids showed weaker, less consistent associations than their ratio.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In this cross-sectional sample, higher CCR was associated with greater odds of dental caries after adjustment for measured covariates. Although elevated CCR may reflect physiological dysregulation associated with chronic stress, it should not be interpreted as a direct measure of stress. These findings are exploratory, require cautious interpretation given the cross-sectional design and absence of a significant unadjusted association, and need confirmation in longitudinal studies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12903-026-08785-7","type":"journal-article","created":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T14:24:11Z","timestamp":1780669451000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Hair cortisol-to-cortisone ratio and dental caries in adolescents: a cross-sectional analysis of glucocorticoid imbalance and caries prevalence"],"prefix":"10.1186","volume":"26","author":[{"given":"Anara","family":"Zhumadilova","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bakytgul","family":"Yermekbayeva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alibek","family":"Kossumov","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Almagul","family":"Kushugulova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samat","family":"Kozhakhmetov","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Modayil","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khyathi","family":"Gadag","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Graciela","family":"Muniz-Terrera","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zelalem T.","family":"Haile","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adil","family":"Supiyev","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,5]]},"reference":[{"key":"8785_CR1","doi-asserted-by":"publisher","first-page":"e109","DOI":"10.1590\/1807-3107bor-2025.vol39.109","volume":"39","author":"EDS Borstmann","year":"2025","unstructured":"Borstmann EDS, Brondani B, Knorst JK, Siqueira BDP, Lima LSD, Ramadan YH, et al. 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