Eur Arch Paediatr Dent (2015) 16:199–204 DOI 10.1007/s40368-014-0155-7
ORIGINAL SCIENTIFIC ARTICLE
Knowledge and behaviour of parents in relation to the oral and dental health of children aged 4–6 years R. ElKarmi • E. Shore • A. O’Connell
Received: 2 July 2014 / Accepted: 22 September 2014 / Published online: 4 November 2014 Ó European Academy of Paediatric Dentistry 2014
Abstract Aim To evaluate baseline knowledge and behaviour of parents with regard to the oral and dental health of their young children. Methods Following ethical approval, six urban and rural schools were identified. Questionnaires were distributed to the parents of pupils (children aged 4–6 years). The questionnaire included several questions evaluating parental knowledge and behaviour of oral and dental health issues in their children. Each question was assigned a score of either 0 or 1 being inconsistent or consistent with current paediatric guidelines giving a maximum score of 6 for knowledge and 7 for behaviour. Chi-square analysis was used to analyse associations among variables. Results Parental knowledge varied widely among parents and across questions; however, 70.2 % of parents had scores greater than 3 (range 0–6). The majority of parents (65.8 %) also had scores greater than 3 (range 0–7) for behaviour. Deficiencies were noted in oral hygiene practices; very few parents brushed their child’s teeth and were not aware of the recommended age of the first dental visit at 1 year (Age 1 visit). Parents without free medical care demonstrated high levels of knowledge (P \ 0.05). Almost half of the parents thought that the information available to them on the oral health of their young children was insufficient. Conclusion Parents appeared to have limited knowledge regarding the dental and oral health of their young children. This study indicates a need for improved education for parents, particularly in toothbrushing behaviour and use of R. ElKarmi (&) E. Shore A. O’Connell Division of Public and Child Dental Health-Dublin Dental University Hospital-Trinity College-Dublin, Lincoln Place, Dublin2, Ireland e-mail: [email protected]
toothpaste. Education strategies tailored to the Irish population should be explored. Keywords Parents Health knowledge Attitudes and practices Dental care for children
Introduction Many parents are unaware that dental caries is the most common chronic infectious disease, being five times more common than asthma (Report of the Surgeon General 2000). Parents often encounter many illnesses during early childhood and attend their medical practitioner on a regular basis. Parents and medical health care workers often minimise the potential contribution of oral and dental health on the general health of their children. Dental caries is common worldwide. The prevalence of caries in 5-year-old children in Ireland was 36.9 % in fluoridated areas and 54.5 % in non-fluoridated areas (Whelton et al. 2004) with the majority of this disease being untreated. This compares to the United States where 41 % of children aged 2–11 years have caries in their primary teeth (Beltra´n-Aguilar et al. 2005), and the United Kingdom where 40 % of 5-year-old children had caries experience (Pitts et al. 2003). Children, in the first years of their lives, spend most of their time at home with their primary caregivers where they start exploring their world. Children acquire daily living skills and knowledge from their parents and up to a certain age they are dependent on their parents in establishing their habits (Prabhu et al. 2013). Dietary and oral hygiene practices are among the living skills children who acquire from their parents, and the oral health status of children often reflects their parents’ knowledge.
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Several authors have reported that parents of children aged 1–6 years had low levels of knowledge and/or poor attitudes with regard to the oral health of their children (Gussy et al. 2008; Ashkanani and Al-Sane 2013; Prabhu et al. 2013). It has been found that low parental knowledge and poor attitudes towards oral health are associated with higher caries experience in infants and young children (Naidu and Davis 2008). Caries experience negatively affects a child’s oral health-related quality of life (Onoriobe et al. 2014). Therefore, caries prevention is essential and should start as early as possible. Anticipatory guidance is the process of providing practical, developmentally appropriate information about children’s health to prepare parents for the significant physical, emotional, and psychological milestones (http://www.AAPD.org/policies). The dental profession embraces the concept that, with early intervention, it may be possible to reduce or eliminate future dental caries (Sanchez and Childers 2000). It has been reported that children who had an early preventive dental visit were more likely to use subsequent preventive service and experience lower dentally related costs (Savage et al. 2004). Therefore, parental education on oral health should be an essential component of caries prevention in preschool children and it has been proven to be effective in reducing the incidence of caries (Rong et al. 2003; Harrison et al. 2007; Tinanoff and Reisine 2009; Kulkarni 2013). For education to be effective and tailored to the unique needs of a population, the existing level of parental knowledge and oral health behaviour needs to be assessed. In a previous study conducted in Ireland to determine the level of parental awareness regarding the oral health of their children, it was found that the majority of parents did not follow oral health recommendations (Lau et al. 2004). Since then, several oral health education-based programmes have been launched targeting both children and parents. This study aimed to measure current baseline knowledge and behaviour of parents in relation to the oral and dental health of their young children.
Materials and methods Ethical approval was obtained from the Faculty of Health Sciences Research Ethics Committee, Trinity College Dublin and permission from the Boards of Management of each school was sought for access to the parents. Participating schools represented both urban and rural schools and were chosen by convenience. Selected schools were all state funded but some schools received additional funding due to social disadvantage under DEIS (Delivering equality of opportunity in schools). Letters and questionnaires were distributed by the school to the parents of pupils aged 4–6 years. The questionnaires were then
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Eur Arch Paediatr Dent (2015) 16:199–204
collected or returned via post 1 week later following a reminder phone call to the school. The questionnaire contained 20 questions with multiple choice option or short answer and enquired about the socioeconomic status of parents as reflected by medical card status the family size, and the ages of children. In Ireland qualification for a medical card is dependant on family income and the size of the family and entitles the recipient to free medical and dental care. Possession of a medical card is used frequently as a measure of social disadvantage. It also included several questions assessing parental knowledge and behaviour regarding certain oral and dental health issues. Six questions assessed parental Table 1 Distribution of parents of Irish 5-year-old children according to their answers to each knowledge question Parental knowledge
Correct knowledge
% of parents with correct knowledge
Age at first primary tooth eruption
4–8 months
66.7
Number of primary teeth at 24 months
16–20 teeth
58.8
Age at first permanent tooth eruption
5–7 years
66.7
Awareness of water fluoridation
Aware
57
Age to start brushing
When teeth erupt
59.6
Risk associated with dark tooth discoloration after trauma
Parents would be concerned
99.1
Table 2 Distribution of parents according to their answers to each behaviour question Parental behaviour/ practice
Recommendation based on current paediatric guidelines
% of parents with behaviour consistent with current guidelines
Age of child at first dental visit
By 1 year of age
2.6
Healthy snack
Fruit–vegetable– nuts–cheese
83.3
Healthy drink
Water and milk
80.7
How often tooth brushing occurs
2 times/day
80.7
Who brushes children’s teeth
Parents
21.9
What tooth paste is used to brush children’s teeth
Adult tooth paste for children over 2 years
17.5
How often children are given between meal snacks per day
3 or less
83.3
Eur Arch Paediatr Dent (2015) 16:199–204
knowledge regarding the age of first primary tooth eruption, the age of first permanent tooth eruption, the total number of primary teeth at 24 months, awareness of water fluoridation, the appropriate age to start brushing, and the risk associated with a dark tooth after dental trauma. Each question was given a score of either 0 or 1, incorrect or correct (Table 1). Seven questions assessed whether parental behaviour was consistent with the recommendations of current paediatric guidelines (http://www.AAPD.org/policies) with score 0 being inconsistent and score 1 consistent (Table 2). These questions explored parental behaviour regarding the age at the first dental visit, healthy snacks, healthy drinks, the number of between meal snacks, the frequency of tooth brushing, parental involvement in tooth brushing, and the type of toothpaste used. The maximum score therefore was 6 for knowledge and 7 for behaviour. Knowledge and behaviour scores were considered low if the parent had a score of 3 or less. Additional questions addressed the reason for the first dental visit, parental behaviour after their child sustains a traumatic dental injury, and whether the information available to parents was sufficient or not. All data were processed and analysed using an SPSS statistical programme (version 16.0). Chi square was used to test the association between different variables with the level of significance set at P \ 0.05.
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Fig. 1 Distribution of parents according to their knowledge scores
Results One hundred and fifty questionnaires were distributed and 114 were returned and usable giving a response rate of 76 %. A high percentage of families (83.3 %) had three children or less, and the majority of parents (71 %) had children older than 6 years with an age range of 7–18 years. Urban schools were more likely to participate with 88 parents responding in urban schools and 26 from rural areas: 77 parents participated from regular schools and 37 from DEIS schools. Forty-three parents (37.4 %) possessed medical cards, the majority of which (65.1 %) belonged to parents of children attending DEIS schools. Family size and school location (urban or rural) had no influence on the level of parental knowledge or behaviour. High knowledge scores were obtained by the majority (80.2 %) of parents of children attending regular schools compared to half (49.6 %) of parents of children attending DEIS schools (P \ 0.05). High knowledge scores were also obtained by 78.9 % of parents without a medical card compared to 55 % of medical card holders (P \ 0.05). The differences in behaviour scores between parents from regular or DEIS schools (P = 0.16) and parents with or without a medical card (P = 0.08) were not statistically
Fig. 2 Distribution of parents according to their answers regarding age of first permanent tooth eruption in 5-year-old Irish children
significant. One half of the parents thought the information available to them was sufficient; however, about one quarter of those had low knowledge scores. There was no statistically significant association between low knowledge or behaviour scores and insufficient information available. Despite the fact that 71 % of parents had children older than 6 years, the level of parental knowledge and behaviour did not seem to be improved by having older children. Figure 1 shows knowledge scores for all parents participating in the study with 70.2 % of parents having a score greater than 3. Table 1 demonstrates the percentages of parents who gave correct answers for each knowledge question. Parental knowledge on the timing of first permanent molar eruption showed that 26 parents (22.8 %) thought eruption occurs after 7 years of age, and 10 parents did not know the timing of eruption (Fig. 2). Almost all parents reported that they would be concerned if their child’s tooth became a darker colour after a traumatic dental injury (Table 1). When asked where they would bring their child after a traumatic dental injury, only 6.1 % of parents would go to a hospital and others would
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Table 3 Distribution of children according to the age at the first dental visit Age at first dental visit (years)
Frequency
Percentage
No visit
40
35.1
1
3
2.6
2 3
4 16
3.5 14
4
19
16.7
5
19
16.7
6
13
11.4
visit the general medical practitioner, the dentist, or do first aid at home. The maximum score for behaviour questions was 7. The most common behaviour score was 4, with 65.8 % of parents having a score greater than 3. Table 2 demonstrates the percentages of parents who gave correct answers for each behaviour question. Very few parents were familiar with the ‘Age 1 visit’ with only 3 families (2.6 %) taking their child to the dentist around his/her first birthday. Less than one quarter of parents participated with their child’s tooth brushing, and only 17.5 % knew the fluoridation status of their drinking water. Table 3 shows that the most common age at which children visited a dentist was 4–5 years. The reason for the first dental visit in 47.4 % of children was a routine check up, but 35.6 % of children had not had a dental visit up to the time their parents participated in the study (age 4–6 years).
Discussion This study aimed at evaluating the knowledge and behaviour of parents in relation to the oral and dental health of children aged 4–6 years in Ireland. Categories of schools (rural, urban, regular, and DEIS) were chosen and then individual schools were identified based on knowledge of cooperation by the Board of Management with research. The majority of medical cards were possessed by parents of children attending DEIS schools confirming the correct use of medical card status as a measure of social disadvantage. This study showed that parents of children attending DEIS schools and those carrying medical cards had low knowledge scores. This correlates with other studies reporting low socioeconomic status to be associated with decreased levels of knowledge (Dykes et al. 2002; Finlayson et al. 2007). Caries prevalence is also associated with low SES and poor knowledge, but children of participating parents were not examined for caries so the association of dental caries with parental factors was not possible from this data.
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In this study, parents who have children older than 6 years of age did not have better knowledge or behaviour scores compared to those whose oldest child was 4–6 years. Therefore, parents are not benefitting from past experiences and tend to continue the high caries risk behaviours with their younger children. Kulkarni et al. (2013) reported some attrition in the information retained by parents over an 18-month time period. Therefore, repeated reinforcement of the same concepts over a shorter time span should be emphasised. The results of this study showed that parents had inadequate knowledge and poor behaviour particularly in brushing their children’s teeth and the use of toothpaste. The answers to questions assessing parental knowledge in relation to basic oral health issues varied among parents and across questions. Almost all parents were aware of the risk associated with dental trauma and reported that they would be concerned if their child’s tooth became a darker colour after a traumatic dental injury. Two-thirds of parents (66.7 %) had correct knowledge regarding the age of first primary and permanent tooth eruption; however, 22.8 % of parents thought that the first permanent tooth would erupt at 7 years or afterwards. More than half (58.8 %) of parents knew that a child would have between 16 and 20 teeth at 2 years. Currently, 71 % of the population in the Republic of Ireland has fluoridated domestic water supplies (Whelton et al. 2002), yet when parents were asked about the status of their water fluoridation, 43 % did not know whether their water supply contained fluoride or not, indicating a possible lack of knowledge of the importance of the role of fluoride in caries prevention. Table 1 shows that about 60 % of parents were aware that tooth brushing should ideally start when the first tooth appears in the child’s mouth. Recently, Mani et al. (2012) reported that 88 % of Malaysian parents agreed that they should brush their baby’s teeth as soon as they erupt. Parental behaviour in relation to the dental health of their children was also variable. More than 80 % of parents gave their children a healthy snack, a healthy drink, and no more than 3 between meal snacks per day (Table 3) which is better than parental behaviour reported in other countries (Chan et al. 2002; Mani et al. 2012). While 80 % of the parents reported that their children’s teeth were brushed twice a day, 78 % did not brush their child’s teeth themselves (Table 2). This is in agreement with a study previously conducted in Ireland where 58 % of children under the age of 7 years brushed their own teeth without supervision (Lau et al. 2004). When parents were asked whether their 4–6 years old used adult or children’s toothpaste, 82.5 % reported using children’s toothpaste. This indicates that many parents are not clear as to whether fluoride should be used in young children and how much should be used, consistent with the findings of Gussy et al. (2008).
Eur Arch Paediatr Dent (2015) 16:199–204
According to the national longitudinal study of the lives of 9 year-olds living in Ireland, the overwhelming majority of children (97 %) reported brushing their teeth at least once daily (Williams et al. 2009). Therefore, there is a definite need for parental education in relation to oral hygiene practices which is consistent with the findings of many studies (Prabhu et al. 2013; Mani et al. 2012). Almost all parents were unaware of the ‘Age 1 dental visit’ and there is no state-funded access for this to occur in Ireland. The most common reported age for the first dental visit was 4–5 years when dietary and oral hygiene practices have already been well established. Age 1 visit aims at helping parents adopt good habits early in life which is much easier than trying to change detrimental oral health behaviours later in a child’s development. The Health Service Executive (HSE) and the Oral Health Foundation in Ireland provide valuable information in relation to the dental care of babies and children electronically through their websites and by means of posters and brochures available at different HSE centres and hospitals. In addition, several oral health education schoolbased programmes have been launched and target young children and their parents. Previously, it was shown that parents had deficient knowledge with regard to their children’s oral health particularly in tooth brushing behaviour (Lau et al. 2004). Comparing the results of this and the previous study, parents continue to have deficient knowledge and poor oral health behaviour. Only one half of parents reported that the information currently available to them is sufficient. This indicates that oral and dental health messages are not being efficiently conveyed to parents through conventional educational means. The effectiveness of parental education has been reported in several studies utilising different strategies. Interactive presentation including the display of video (Kulkarni 2013), one to one videotaped oral health message based upon the self determination theory (autonomous self regulation, intrinsic motivation) (Weber-Gasparoni et al. 2013), and motivational interviewing (Harrison et al. 2007) have all proven to be effective education tools when compared with conventional education means. In addition, repeated rounds of anticipatory guidance initiated during the mother’s pregnancy and home visits for dietary advice within 10 days of the child’ birth and repeated monthly up to 6 months has proved to be effective in reducing dental caries in infants and young children (Feldens et al. 2007; Plutzer and Spencer 2008; Duane 2012). Given the lack of improvement using conventional campaigns, it would be valuable to explore these more recent methods. In addition, medical personnel should be targeted to reinforce oral health messages to parents especially that access to dental care at younger ages is not state funded in Ireland.
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Conclusion There has been no improvement in parental oral health knowledge of their young children despite education campaigns over the past 10 years. Parents in Ireland appeared to have inadequate tooth brushing behaviours towards their young children. Promoting oral health care as part of general health is an important goal for education. Given that many parents do not access dentistry for their young children, all health care professionals should have sufficient knowledge to inform parents of positive behaviours to reduce caries in their young children prior to school entry.
References American Academy of Pediatric Dentistry. Available at http://www. AAPD.org/policies/. Accessed 19 Sept 2014. Ashkanani F, Al-Sane M. Knowledge, attitude and practices of caregivers in relation to oral health of preschool children. Med Princ Pract. 2013;22:167–72. Beltra´n-Aguilar ED, Barker LK, Canto MT et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis—United States, 1988–1994 and 1999–2002. MMWR Surveill Summ 2005; 541–43. Chan SC, Tsai JS, King NM. Feeding and oral hygiene habits of preschool children in Hong Kong and their caregivers’ dental knowledge and attitudes. Int J Paediatr Dent. 2002;12:322–31. Duane B. Home visits or telephone contacts may help prevent early childhood caries. Evid Based Dent 2012;13:39–40. Dykes J, Watt RG, Nazroo J. Socio-economic and ethnic influences on infant feeding practices related to oral health. Community Dent Health. 2002;19:137–43. Feldens CA, Vitolo MR, Drachler ML. A randomized trial of the effectiveness of home visits in preventing early childhood caries. Comm Dent Oral Epidemiol 2007;35:215–23. Finlayson TL, Siefert K, Ismail AI, Sohn W. Maternal self-efficacy and 1–5-Year-Old children’s brushing habits. Community Dent Oral Epidemiol. 2007;35:272–81. Gussy MG, Waters EB, Riggs EM, Lo SK, Kilpatrick NM. Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria. Aust Dent J. 2008;53:52–60. Harrison R, Benton T, Everson-Stewart S, Weinstein P. Effect of motivational interviewing on rates of early childhood caries: a randomized trial. Pediatr Dent. 2007;29:16–22. Kulkarni G. Long-term effectiveness of parent education using the ‘‘baby oral health’’ model on the improvement of oral health of young children, Int J Dent. 2013. Epub Nov 10. Lau AC, Agarwal RR, Banerjee T, et al. A survey of parental knowledge of paediatric oral health in Ireland. Ir Med J. 2004;97:53–5. Mani SA, John J, Ping W, Ismail NM. Early childhood caries: parent’s knowledge, attitude and practice towards its prevention in Malaysia, http://www.intechopen.com/download/pdf/29333. 2012. Naidu RS, Davis L. Parents’ views on factors influencing the dental health of Trinidadian pre-school children. Community Dent Health. 2008;25:44–9. Onoriobe U,Rozier RG, Cantrell J, King RS. Effects of Enamel Fluorosis and Dental Caries on Quality of Life. J Dent Res 2014; 93: 972–9. pii:0022034514548705
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204 Pitts NB, Boyles J, Nugent ZJ, Thomas N, Pine CM. The dental caries experience of 5-year-old children in England and Wales. Surveys coordinated by the British Association for the Study of Community Dentistry in 2001/2002. Community Dent Health. 2003;20:45–54. Plutzer K, Spencer AJ. Efficacy of an oral health promotion intervention in the prevention of early childhood caries. Comm Dent Oral Edpidemiol 2008;36:335–46. Prabhu A, Rao AP, Reddy V, et al. Parental knowledge of preschool child oral health. J Community Health. 2013;38:880–4. Rong WS, Bian JY, Wang WJ, Wang JD. Effectiveness of an oral health education and caries prevention program in kindergartens in China. Community Dent Oral Epidemiol. 2003;31:412–6. Sanchez OM, Childres NK. Anticipatory guidance in infant oral health : rational and recommendations. Am Fam Physician 2000; 61:115–120. Savage MF, Lee JY, Kotch JB, Vann WFJ. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics. 2004;114:418–23. Tinanoff N, Reisine S. Update on early childhood caries since the surgeon general’s report. Acad Pediatr. 2009;9:396–403.
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Eur Arch Paediatr Dent (2015) 16:199–204 US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. Available at http://www.nidcr.nih.gov/datastatistics/sur geongeneral/. Accessed 10 Sept 2014. Weber-Gasparoni K, Reeve J, Ghosheh N, et al. An effective psychoeducational intervention for early childhood caries prevention: part I. Pediatr Dent. 2013;35:241–6. Whelton H, Crowley E, O’Mullane D, et al. Dental caries and enamel fluorosis among the fluoridated and non-fluoridated populations in the Republic of Ireland in 2002. Community Dent Health. 2004;21:37–44. Whelton H, Crowley E, O’Mullane D et al. North South Survey of Children’s Oral Health in Ireland 2002. Dublin: Department of Health and Children. Available at: http://www.dohc.ie/publica tions/oral_health.html. Accessed 10 Sept 2014. Williams J, Greene S, Doyle E et al. Growing up in Ireland: The lives of 9–year-olds, 2009. Available at http://www.growingup.ie/ index.php?id=62. Accessed 10 Sept 2014.
ORIGINAL SCIENTIFIC ARTICLE
Knowledge and behaviour of parents in relation to the oral and dental health of children aged 4–6 years R. ElKarmi • E. Shore • A. O’Connell
Received: 2 July 2014 / Accepted: 22 September 2014 / Published online: 4 November 2014 Ó European Academy of Paediatric Dentistry 2014
Abstract Aim To evaluate baseline knowledge and behaviour of parents with regard to the oral and dental health of their young children. Methods Following ethical approval, six urban and rural schools were identified. Questionnaires were distributed to the parents of pupils (children aged 4–6 years). The questionnaire included several questions evaluating parental knowledge and behaviour of oral and dental health issues in their children. Each question was assigned a score of either 0 or 1 being inconsistent or consistent with current paediatric guidelines giving a maximum score of 6 for knowledge and 7 for behaviour. Chi-square analysis was used to analyse associations among variables. Results Parental knowledge varied widely among parents and across questions; however, 70.2 % of parents had scores greater than 3 (range 0–6). The majority of parents (65.8 %) also had scores greater than 3 (range 0–7) for behaviour. Deficiencies were noted in oral hygiene practices; very few parents brushed their child’s teeth and were not aware of the recommended age of the first dental visit at 1 year (Age 1 visit). Parents without free medical care demonstrated high levels of knowledge (P \ 0.05). Almost half of the parents thought that the information available to them on the oral health of their young children was insufficient. Conclusion Parents appeared to have limited knowledge regarding the dental and oral health of their young children. This study indicates a need for improved education for parents, particularly in toothbrushing behaviour and use of R. ElKarmi (&) E. Shore A. O’Connell Division of Public and Child Dental Health-Dublin Dental University Hospital-Trinity College-Dublin, Lincoln Place, Dublin2, Ireland e-mail: [email protected]
toothpaste. Education strategies tailored to the Irish population should be explored. Keywords Parents Health knowledge Attitudes and practices Dental care for children
Introduction Many parents are unaware that dental caries is the most common chronic infectious disease, being five times more common than asthma (Report of the Surgeon General 2000). Parents often encounter many illnesses during early childhood and attend their medical practitioner on a regular basis. Parents and medical health care workers often minimise the potential contribution of oral and dental health on the general health of their children. Dental caries is common worldwide. The prevalence of caries in 5-year-old children in Ireland was 36.9 % in fluoridated areas and 54.5 % in non-fluoridated areas (Whelton et al. 2004) with the majority of this disease being untreated. This compares to the United States where 41 % of children aged 2–11 years have caries in their primary teeth (Beltra´n-Aguilar et al. 2005), and the United Kingdom where 40 % of 5-year-old children had caries experience (Pitts et al. 2003). Children, in the first years of their lives, spend most of their time at home with their primary caregivers where they start exploring their world. Children acquire daily living skills and knowledge from their parents and up to a certain age they are dependent on their parents in establishing their habits (Prabhu et al. 2013). Dietary and oral hygiene practices are among the living skills children who acquire from their parents, and the oral health status of children often reflects their parents’ knowledge.
123
200
Several authors have reported that parents of children aged 1–6 years had low levels of knowledge and/or poor attitudes with regard to the oral health of their children (Gussy et al. 2008; Ashkanani and Al-Sane 2013; Prabhu et al. 2013). It has been found that low parental knowledge and poor attitudes towards oral health are associated with higher caries experience in infants and young children (Naidu and Davis 2008). Caries experience negatively affects a child’s oral health-related quality of life (Onoriobe et al. 2014). Therefore, caries prevention is essential and should start as early as possible. Anticipatory guidance is the process of providing practical, developmentally appropriate information about children’s health to prepare parents for the significant physical, emotional, and psychological milestones (http://www.AAPD.org/policies). The dental profession embraces the concept that, with early intervention, it may be possible to reduce or eliminate future dental caries (Sanchez and Childers 2000). It has been reported that children who had an early preventive dental visit were more likely to use subsequent preventive service and experience lower dentally related costs (Savage et al. 2004). Therefore, parental education on oral health should be an essential component of caries prevention in preschool children and it has been proven to be effective in reducing the incidence of caries (Rong et al. 2003; Harrison et al. 2007; Tinanoff and Reisine 2009; Kulkarni 2013). For education to be effective and tailored to the unique needs of a population, the existing level of parental knowledge and oral health behaviour needs to be assessed. In a previous study conducted in Ireland to determine the level of parental awareness regarding the oral health of their children, it was found that the majority of parents did not follow oral health recommendations (Lau et al. 2004). Since then, several oral health education-based programmes have been launched targeting both children and parents. This study aimed to measure current baseline knowledge and behaviour of parents in relation to the oral and dental health of their young children.
Materials and methods Ethical approval was obtained from the Faculty of Health Sciences Research Ethics Committee, Trinity College Dublin and permission from the Boards of Management of each school was sought for access to the parents. Participating schools represented both urban and rural schools and were chosen by convenience. Selected schools were all state funded but some schools received additional funding due to social disadvantage under DEIS (Delivering equality of opportunity in schools). Letters and questionnaires were distributed by the school to the parents of pupils aged 4–6 years. The questionnaires were then
123
Eur Arch Paediatr Dent (2015) 16:199–204
collected or returned via post 1 week later following a reminder phone call to the school. The questionnaire contained 20 questions with multiple choice option or short answer and enquired about the socioeconomic status of parents as reflected by medical card status the family size, and the ages of children. In Ireland qualification for a medical card is dependant on family income and the size of the family and entitles the recipient to free medical and dental care. Possession of a medical card is used frequently as a measure of social disadvantage. It also included several questions assessing parental knowledge and behaviour regarding certain oral and dental health issues. Six questions assessed parental Table 1 Distribution of parents of Irish 5-year-old children according to their answers to each knowledge question Parental knowledge
Correct knowledge
% of parents with correct knowledge
Age at first primary tooth eruption
4–8 months
66.7
Number of primary teeth at 24 months
16–20 teeth
58.8
Age at first permanent tooth eruption
5–7 years
66.7
Awareness of water fluoridation
Aware
57
Age to start brushing
When teeth erupt
59.6
Risk associated with dark tooth discoloration after trauma
Parents would be concerned
99.1
Table 2 Distribution of parents according to their answers to each behaviour question Parental behaviour/ practice
Recommendation based on current paediatric guidelines
% of parents with behaviour consistent with current guidelines
Age of child at first dental visit
By 1 year of age
2.6
Healthy snack
Fruit–vegetable– nuts–cheese
83.3
Healthy drink
Water and milk
80.7
How often tooth brushing occurs
2 times/day
80.7
Who brushes children’s teeth
Parents
21.9
What tooth paste is used to brush children’s teeth
Adult tooth paste for children over 2 years
17.5
How often children are given between meal snacks per day
3 or less
83.3
Eur Arch Paediatr Dent (2015) 16:199–204
knowledge regarding the age of first primary tooth eruption, the age of first permanent tooth eruption, the total number of primary teeth at 24 months, awareness of water fluoridation, the appropriate age to start brushing, and the risk associated with a dark tooth after dental trauma. Each question was given a score of either 0 or 1, incorrect or correct (Table 1). Seven questions assessed whether parental behaviour was consistent with the recommendations of current paediatric guidelines (http://www.AAPD.org/policies) with score 0 being inconsistent and score 1 consistent (Table 2). These questions explored parental behaviour regarding the age at the first dental visit, healthy snacks, healthy drinks, the number of between meal snacks, the frequency of tooth brushing, parental involvement in tooth brushing, and the type of toothpaste used. The maximum score therefore was 6 for knowledge and 7 for behaviour. Knowledge and behaviour scores were considered low if the parent had a score of 3 or less. Additional questions addressed the reason for the first dental visit, parental behaviour after their child sustains a traumatic dental injury, and whether the information available to parents was sufficient or not. All data were processed and analysed using an SPSS statistical programme (version 16.0). Chi square was used to test the association between different variables with the level of significance set at P \ 0.05.
201
Fig. 1 Distribution of parents according to their knowledge scores
Results One hundred and fifty questionnaires were distributed and 114 were returned and usable giving a response rate of 76 %. A high percentage of families (83.3 %) had three children or less, and the majority of parents (71 %) had children older than 6 years with an age range of 7–18 years. Urban schools were more likely to participate with 88 parents responding in urban schools and 26 from rural areas: 77 parents participated from regular schools and 37 from DEIS schools. Forty-three parents (37.4 %) possessed medical cards, the majority of which (65.1 %) belonged to parents of children attending DEIS schools. Family size and school location (urban or rural) had no influence on the level of parental knowledge or behaviour. High knowledge scores were obtained by the majority (80.2 %) of parents of children attending regular schools compared to half (49.6 %) of parents of children attending DEIS schools (P \ 0.05). High knowledge scores were also obtained by 78.9 % of parents without a medical card compared to 55 % of medical card holders (P \ 0.05). The differences in behaviour scores between parents from regular or DEIS schools (P = 0.16) and parents with or without a medical card (P = 0.08) were not statistically
Fig. 2 Distribution of parents according to their answers regarding age of first permanent tooth eruption in 5-year-old Irish children
significant. One half of the parents thought the information available to them was sufficient; however, about one quarter of those had low knowledge scores. There was no statistically significant association between low knowledge or behaviour scores and insufficient information available. Despite the fact that 71 % of parents had children older than 6 years, the level of parental knowledge and behaviour did not seem to be improved by having older children. Figure 1 shows knowledge scores for all parents participating in the study with 70.2 % of parents having a score greater than 3. Table 1 demonstrates the percentages of parents who gave correct answers for each knowledge question. Parental knowledge on the timing of first permanent molar eruption showed that 26 parents (22.8 %) thought eruption occurs after 7 years of age, and 10 parents did not know the timing of eruption (Fig. 2). Almost all parents reported that they would be concerned if their child’s tooth became a darker colour after a traumatic dental injury (Table 1). When asked where they would bring their child after a traumatic dental injury, only 6.1 % of parents would go to a hospital and others would
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Table 3 Distribution of children according to the age at the first dental visit Age at first dental visit (years)
Frequency
Percentage
No visit
40
35.1
1
3
2.6
2 3
4 16
3.5 14
4
19
16.7
5
19
16.7
6
13
11.4
visit the general medical practitioner, the dentist, or do first aid at home. The maximum score for behaviour questions was 7. The most common behaviour score was 4, with 65.8 % of parents having a score greater than 3. Table 2 demonstrates the percentages of parents who gave correct answers for each behaviour question. Very few parents were familiar with the ‘Age 1 visit’ with only 3 families (2.6 %) taking their child to the dentist around his/her first birthday. Less than one quarter of parents participated with their child’s tooth brushing, and only 17.5 % knew the fluoridation status of their drinking water. Table 3 shows that the most common age at which children visited a dentist was 4–5 years. The reason for the first dental visit in 47.4 % of children was a routine check up, but 35.6 % of children had not had a dental visit up to the time their parents participated in the study (age 4–6 years).
Discussion This study aimed at evaluating the knowledge and behaviour of parents in relation to the oral and dental health of children aged 4–6 years in Ireland. Categories of schools (rural, urban, regular, and DEIS) were chosen and then individual schools were identified based on knowledge of cooperation by the Board of Management with research. The majority of medical cards were possessed by parents of children attending DEIS schools confirming the correct use of medical card status as a measure of social disadvantage. This study showed that parents of children attending DEIS schools and those carrying medical cards had low knowledge scores. This correlates with other studies reporting low socioeconomic status to be associated with decreased levels of knowledge (Dykes et al. 2002; Finlayson et al. 2007). Caries prevalence is also associated with low SES and poor knowledge, but children of participating parents were not examined for caries so the association of dental caries with parental factors was not possible from this data.
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In this study, parents who have children older than 6 years of age did not have better knowledge or behaviour scores compared to those whose oldest child was 4–6 years. Therefore, parents are not benefitting from past experiences and tend to continue the high caries risk behaviours with their younger children. Kulkarni et al. (2013) reported some attrition in the information retained by parents over an 18-month time period. Therefore, repeated reinforcement of the same concepts over a shorter time span should be emphasised. The results of this study showed that parents had inadequate knowledge and poor behaviour particularly in brushing their children’s teeth and the use of toothpaste. The answers to questions assessing parental knowledge in relation to basic oral health issues varied among parents and across questions. Almost all parents were aware of the risk associated with dental trauma and reported that they would be concerned if their child’s tooth became a darker colour after a traumatic dental injury. Two-thirds of parents (66.7 %) had correct knowledge regarding the age of first primary and permanent tooth eruption; however, 22.8 % of parents thought that the first permanent tooth would erupt at 7 years or afterwards. More than half (58.8 %) of parents knew that a child would have between 16 and 20 teeth at 2 years. Currently, 71 % of the population in the Republic of Ireland has fluoridated domestic water supplies (Whelton et al. 2002), yet when parents were asked about the status of their water fluoridation, 43 % did not know whether their water supply contained fluoride or not, indicating a possible lack of knowledge of the importance of the role of fluoride in caries prevention. Table 1 shows that about 60 % of parents were aware that tooth brushing should ideally start when the first tooth appears in the child’s mouth. Recently, Mani et al. (2012) reported that 88 % of Malaysian parents agreed that they should brush their baby’s teeth as soon as they erupt. Parental behaviour in relation to the dental health of their children was also variable. More than 80 % of parents gave their children a healthy snack, a healthy drink, and no more than 3 between meal snacks per day (Table 3) which is better than parental behaviour reported in other countries (Chan et al. 2002; Mani et al. 2012). While 80 % of the parents reported that their children’s teeth were brushed twice a day, 78 % did not brush their child’s teeth themselves (Table 2). This is in agreement with a study previously conducted in Ireland where 58 % of children under the age of 7 years brushed their own teeth without supervision (Lau et al. 2004). When parents were asked whether their 4–6 years old used adult or children’s toothpaste, 82.5 % reported using children’s toothpaste. This indicates that many parents are not clear as to whether fluoride should be used in young children and how much should be used, consistent with the findings of Gussy et al. (2008).
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According to the national longitudinal study of the lives of 9 year-olds living in Ireland, the overwhelming majority of children (97 %) reported brushing their teeth at least once daily (Williams et al. 2009). Therefore, there is a definite need for parental education in relation to oral hygiene practices which is consistent with the findings of many studies (Prabhu et al. 2013; Mani et al. 2012). Almost all parents were unaware of the ‘Age 1 dental visit’ and there is no state-funded access for this to occur in Ireland. The most common reported age for the first dental visit was 4–5 years when dietary and oral hygiene practices have already been well established. Age 1 visit aims at helping parents adopt good habits early in life which is much easier than trying to change detrimental oral health behaviours later in a child’s development. The Health Service Executive (HSE) and the Oral Health Foundation in Ireland provide valuable information in relation to the dental care of babies and children electronically through their websites and by means of posters and brochures available at different HSE centres and hospitals. In addition, several oral health education schoolbased programmes have been launched and target young children and their parents. Previously, it was shown that parents had deficient knowledge with regard to their children’s oral health particularly in tooth brushing behaviour (Lau et al. 2004). Comparing the results of this and the previous study, parents continue to have deficient knowledge and poor oral health behaviour. Only one half of parents reported that the information currently available to them is sufficient. This indicates that oral and dental health messages are not being efficiently conveyed to parents through conventional educational means. The effectiveness of parental education has been reported in several studies utilising different strategies. Interactive presentation including the display of video (Kulkarni 2013), one to one videotaped oral health message based upon the self determination theory (autonomous self regulation, intrinsic motivation) (Weber-Gasparoni et al. 2013), and motivational interviewing (Harrison et al. 2007) have all proven to be effective education tools when compared with conventional education means. In addition, repeated rounds of anticipatory guidance initiated during the mother’s pregnancy and home visits for dietary advice within 10 days of the child’ birth and repeated monthly up to 6 months has proved to be effective in reducing dental caries in infants and young children (Feldens et al. 2007; Plutzer and Spencer 2008; Duane 2012). Given the lack of improvement using conventional campaigns, it would be valuable to explore these more recent methods. In addition, medical personnel should be targeted to reinforce oral health messages to parents especially that access to dental care at younger ages is not state funded in Ireland.
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Conclusion There has been no improvement in parental oral health knowledge of their young children despite education campaigns over the past 10 years. Parents in Ireland appeared to have inadequate tooth brushing behaviours towards their young children. Promoting oral health care as part of general health is an important goal for education. Given that many parents do not access dentistry for their young children, all health care professionals should have sufficient knowledge to inform parents of positive behaviours to reduce caries in their young children prior to school entry.
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