ORIGINAL Begzati ARTICLE et al
Mothers’ Behaviours and Knowledge Related to Caries Experience of Their Children Agim Begzatia/Ariana Bytycib/Kastriot Meqac/Blerta Latifi-Xhemajlid/Merita Berishae
Purpose: Insufficient attention paid by public institutions to primary oral health protection measures has contributed to a poor oral health status in Kosovo, especially in children. Because the oral health promotion activities identified the significant roles of mothers in primary prevention, the aim of this study was to determine the level of knowledge and the behaviour of mothers in connection with the caries experience of their children. Materials and Methods: 664 of the mothers who accompanied their children to dental visits were interviewed and data on maternal knowledge and attitudes towards the oral health of preschool children were collected. The children underwent dental examination and the dmft index was recorded. Results: The mean dmft index in all children was 6.30 ± 3.23. A high prevalence of early childhood caries was recorded. The highest mean dmft was recorded for children whose mothers had finished primary and secondary school (6.41 ± 3.36 and 6.62 ± 2.87, respectively). The mothers displayed insufficient knowledge regarding dental visits, feeding, oral hygiene maintenance and the utilisation of fluoride/antimicrobial agents. Conclusions: The results of this study show that the level of knowledge about oral health among interviewed mothers is very low to nonexistent. Mothers need to be educated and encouraged that they are a key factor in improving the oral health habits of their children. Since caries represents a serious public health problem in Kosovo, an overall preventive programme for oral health promotion is needed, including the oral health education of mothers. Key words: caries experience of preschool children, mothers’ knowledge, oral health education Oral Health Prev Dent 2014;2:133-140
Submitted for publication: 10.07.12; accepted for publication: 26.02.13
doi: 10.3290/j.ohpd.a31667
D
ental caries is one of the most prevalent diseases in children worldwide. The Centers for Disease Control (CDC) and Prevention has reported that caries is perhaps the most prevalent disease
a
Associate Professor and Head of Department, Paedodontics and Preventive Dentistry, School of Dentistry, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
b
Dental Hygienist in Private Practice, Prishtina, Kosovo; Oral Health Promotion Group of Kosovo.
c
Assistant and PhD Candidate, Department of Periodontology and Oral Medicine, School of Dentistry, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
d
Assistant and PhD Student, Department of Paedodontics and Preventive Dentistry, School of Dentistry, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
e
Associate Professor, National Institute of Public Health, Department of Statistics, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
Correspondence: Associate Professor Agim B. Begzati, School of Dentistry, University of Prishtina, Lagja e Spitalit str, NN, 10000 Prishtina, Kosovo. Tel: +377-44-124-092, Fax: +381-38-512-474 Email: [email protected] or [email protected]
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in children (US Department of Health, 2000). Epidemiological data derived from the Oral Health Promotion Group of Kosovo showed a high prevalence of caries among children in Kosovo (89.2% among preschool children and 94.4% among schoolchildren). The mean dmft/DMFT index was 5.6 for preschool children and 4.9 for all schoolchildren (Begzati et al, 2011). A severe category of caries that is very common among children of preschool age is known as early childhood caries (ECC). In a previous study, caries risk factors and the clinical consequences of ECC in preschool children of Kosovo were discussed (Begzati et al, 2010). Drury et al (1999) and Menghini et al (2003) recommended that additional research be conducted on the epidemiology, aetiology and effective prevention of caries in preschool-aged children due to lack of information in this area. The diagnosis of noncavitated carious lesions provides more useful data on the caries process in primary teeth and may aid in understanding the progression of caries during ear-
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ly childhood (Drury et al, 1999). Researchers have attempted to describe the cause, treatment and prevention of caries from a microbiological perspective (Berkowitz, 2003). In addition, there are many social, demographic and behavioural factors such as family income, family status, toothbrushing habits, parental knowledge and maternal educational level (Reisine et al, 1994; Tinanoff and O’Sullivan, 1997) which influence oral health during childhood. It has been suggested that family history has an impact on the outcome of non-genetic factors, e.g. environmental factors, exposures and common behaviours (Shearer et al, 2011). In order to improve the oral health of small children, it is important to convince parents to actively participate in preserving the dental health of their offspring (Menghini et al, 2008). Children under the age of 5 years spend most of their time with mothers; during this time, the earliest childhood routines and habits are acquired. These include healthy behaviours and dietary habits as practiced in the home, which are dependent on the knowledge and behaviour of the parents. Parents’ knowledge and beliefs, which affect oral hygiene and healthy eating habits, thus influence children’s oral health maintenance and outcomes (Suresh et al, 2010). Within the family, the mother’s role has been emphasised in relation to the child’s oral health habits and status. Considering the close interaction between mother and child, the mother’s role is an important resource for the child’s perception and acceptance of attitudes, values and behaviours (Saied-Moallemi et al, 2008). The oral health knowledge of mothers and oral health-related habits (toothbrushing, diet, food choices) are directly associated with the oral health and diet of the children (Suresh et al, 2010; Dye et al, 2011). Mothers with a higher education have better knowledge regarding the oral hygiene practices and the importance of deciduous teeth (Suresh et al, 2010). Children’s dietary habits also vary according to their mothers’ educational level: low-education, low-income families consume foods higher in added sugars (Dye et al, 2011). A study by Williams et al (2002) showed that the caries experience in 3-yearold children was associated with a low level of oral health-related knowledge among mothers. In contrast, the frequent dental visits of mothers with a highschool or university education shows an increase in oral health awareness (Silver, 1992). Based on the complexity of factors related to caries, the role of oral health education is believed to
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be very important, especially for mothers. As provided by dental professionals, counseling of mothers about the oral health of their children increased their knowledge and improved their attitude towards the dental health of their children (Blinkhorn et al, 2003). Thus, the aim of this study was to determine the level of knowledge and the behaviour of the mothers in connection with the caries experience of their children.
MATERIALS AND METHODS Interviewing of mothers In a one-year period at the Department of Paediatric and Preventive Dentistry, School of Dentistry, University of Prishtina, 664 children from 803 first visits of preschool children were selected for examination and at the same time their mothers were interviewed. Children were not included in the study if they were accompanied by someone other than their mother, their mothers refused to be interviewed, were part of group visits or had special needs. This study was approved by the University of Prishtina School of Dentistry’s Ethics Board. All participants completed the informed consent form. The mothers were interviewed to collect data regarding their knowledge of oral hygiene practices, diet and feeding habits, fluoride and use of antimicrobial agents for their children. The mothers were also interviewed about dental visits during pregnancy and their children’s first dental visit. The interviews were conducted in a quiet room using direct communication with the subjects. Regarding the educational levels, mothers were divided into three groups: highschool or university education (14–16 years of education), secondary school education (up to 12 years) and primary school education (up to 8 years).
Dental examination of children All children underwent dental examinations for dental status according to the World Health Organization criteria (WHO, 1987). Children were examined using the light from the dental unit, a dental mirror and a dental probe. A carious lesion was recorded when the carious cavity was clearly evident upon visual inspection of the child sitting up-
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Table 1 Basic characteristics of interviewed mothers Mothers’ age Mothers’ education
N
%
mean ± SD
Primary
188
28
Secondary
394
Highschool or university Total
Table 2
Employment rate
Number of children
Age of children
N
%
mean ± SD
mean ± SD
28.80 ± 5.88
43
23
3.32 ± 1.06
3.90 ± 1.08
59
29.82 ± 4.29
205
52
3.13 ± 1.29
4.56 ± 1.20
82
13
28.20 ± 5.08
49
60
1.82 ± 0.63
3.22 ± 0.93
664
100
29.33 ± 4.92
297
45
3.02 ± 1.25
4.22 ± 1.23
Mean dmft of children according to gender, mother’s education and reason for dental visit
Mean dmft by gender
N
%
Mean dmft ± SD
t-test
F
326
49
6.39 ± 3.26
t = 0.68
M
338
51
6.22 ± 3.19
P > 0.05
Total
664
100
6.30 ± 3.23
1. Primary school
188
28
6.41 ± 3.36
1 vs 2 (t = 0.74) P > 0.05
2. Secondary school
394
59
6.62 ± 2.87
1 vs 3 (t = 4.01) P < 0.001
82
13
4.49 ± 3.24
2 vs 3 (t = 4.89) P 0.05). The dmft index of the children whose mothers had finished highschool or university was significantly lower
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Table 3
Children with ECC (N = 664)
Gender
N
%
Mean dmft ± SD
t-test
f
65
48
11.17 ± 2.66
t = 0.21
m
70
52
11.07 ± 2.82
P > 0.05
135
100
11.04 ± 2.80
Total
Table 5 Children’s habits and mothers’ knowledge regarding oral health practices Children’s daily frequency of toothbrushing
Never
38%
Once
51%
Twice
11%
Children’s daily frequency of sweets consumption Rarely
Table 4 Mothers’ dental visits during pregnancy and children’s first dental visit Mothers’ dental experience during pregnancy Dental visit
N
%
469
71
Yes, for advice
53
8
Other reasons (pain, bleeding gums)
142
21
Total
664
No
P-value
r2 = 433.59 P < 0.0001
100
24%
At least twice a day
67%
Children who consume sweets between meals
69%
Bottle feeding No
15%
Less than 1 year of age
20%
More than 1 year of age
65%
Children who sleep with bottle
74%
Mother knows about negative effects of bottle feeding
12%
Mother ‘tastes’ child’s food
35%
Mother knows about proper tooth brushing technique 40
6
After one year
120
18
r2 = 357.41
After 3 years
384
58
P < 0.0001
Do not know
120
18
Total
664
100
(P 0.05). The dental experience of the children proved to be unpleasant. In 65% of the cases, the mothers stated that children visited the dentist because of toothaches. These children’s mean dmft was 6.69 (SD 3.54). This mean dmft was significantly higher compared with cases involving children seen by a dentist for advice (P < 0.001). The prevalence of ECC was 21% and the mean dmft in children with ECC was 11.04 (SD 2.8). There was no significant difference between the genders (P > 0.05) (Table 3).
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At least once a day
Mother assists or brushes child’s teeth
Children’s first dental visit On eruption
9%
5% 11%
Mothers’ knowledge on toothbrushing duration At least 2 to 3 min
24%
Don’t know
76%
Fluoride or antimicrobial agent utilisation in their children
0%
Mothers’ dental experience during pregnancy shows a significant difference in terms of the reason for the dental visit (P < 0.001) (Table 4). Most of the interviewed mothers (71%) reported that during the pregnancy they did not visit the dentist at all. Only 8% of them visited the dentist for advice, whereas 21% visited the dentist because of pain or gingival bleeding (21%). Significant differences were found for mothers’ responses about when the child’s first dental visit should take place (P < 0.001) (Table 4). More than half (58%) of the mothers reported that the first dental visit should be done after the age of three. The data concerning children’s oral hygiene, sweets consumption and bottle feeding are presented in Table 5. A high percentage of children
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(38%) did not brush their teeth at all and the consumption of sweets was very high. Two-thirds of the children consumed sweets twice or more each day (67%) and unfortunately, 69% of the children reported consuming sweets between meals. Bottle feeding for a duration of more than one year was practiced in 65% of the children. A very high percentage of children (74%) slept with the bottle. Mothers’ knowledge regarding the influence of bottle feeding on ECC occurrence was scarce, with only 12% acknowledging its negative role. Another unhealthy habit was identified, which involved the mothers’ tasting the spoon first to check whether the food was hot before feeding their children. This practice was confirmed by 35% of the mothers. Maternal knowledge and habits on oral health practices are also presented in Table 5. Only 5% of the mothers assisted their children during toothbrushing. The proper technique of toothbrushing was reported by only 11% of the mothers and toothbrushing duration of at least 2 to 3 min was reported by 24% of them. There was an overall absence of fluoride use by the mothers, as they were not aware of the role of this essential element; neither were they informed about any antimicrobial agents.
DISCUSSION Kosovo is a country in southeastern Europe with a population of about 2 million. As a result of the high birth rate, Kosovo’s demographic structure is characterised by a large proportion of youth. In 2008, the publication ‘Women and Men of Kosovo’, reported that 46% of Kosovo’s population was under 18 (KSO, 2008). Nevertheless, public institutions in Kosovo have paid insufficient attention to primary oral healthcare measures, especially for children. As an exception, volunteer activities have been organised by the Oral Health Promotion Group established within the University of Prishtina’s School of Dentistry. The importance of the role of mothers in maintaining good oral health in their children is beyond doubt. The mother’s level of education is quite important, especially in Kosovo, where women are not sufficiently educated. According to the official data, nearly half of all women completed only their primary education (44.9%) while only 7.2% had finished highschool or obtained a university degree. Unfortunately, even in this century, illiteracy exists
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in Kosovo, at a rate of around 6% and the number of illiterate women is almost three times higher than that of men. Demographic data are characterised by a high birth rate (15.7%), equivalent to an average of three children per mother. Social data show low employment rates among women (approximately 60%). Even though the prevalence of women is very high in trade and services such as health or education, oral health education has been mostly ignored (KSO, 2008). These official data regarding the education and employment rate of mothers are essentially identical with the results of the present study. The current results show that mothers’ oral hygiene efforts and their knowledge of oral health protection for their children are largely inadequate. This inadequacy is reflected in the dental status of the children, with a mean dmft of 6.3. The highest mean dmft was recorded for children whose mothers finished primary and secondary school (6.4 and 6.6, respectively), while a lower mean dmft (4.5) was recorded for children whose mothers finished highschool or obtained a university degree. Although mothers with a highschool or university education had more oral health knowledge as evidenced by the lower mean dmft, dmft was still high according to WHO standards. The children’s dental health status was even worse given the high prevalence of ECC (above 21%), with a mean dmft of 11 for these cases. Not surprisingly, nearly two-thirds of all children in this study unfortunately visited the dentist only in the presence of pain. This study focused on maternal levels of knowledge regarding oral health, especially since mothers play crucial roles in educating their children. However, an attempt was also made to increase the awareness of not only mothers but also health professionals regarding the importance of the early prevention of dental and oral diseases in children through pre- and postnatal health education. Health education ought to start during the prenatal period. It consists of regular OB/GYN visits and adequate access to necessary medical care to promote good maternal and paediatric health. Unfortunately, only 8% of the mothers sought advice from their obstetrician regarding oral health protection measures for their future child. Nearly three-quarters of the mothers neglected dental visits during their pregnancies. Even though mothers reported occasional discomfort regarding their oral health, such as gingival bleeding or toothaches, their visits to the dentist were very rare, with only 21% seeking
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help from a dentist. Another factor driving maternal negligence towards their own oral health was the inadequate level of awareness among healthcare personnel, as well as their hesitant attitudes. According to the U.S. Department of Health and Human Services (US Department of Health and Human Services, 2003), improving oral health during pregnancy not only enhances the overall health of women, but also contributes to improved oral health for their children. In keeping with the mothers’ rare visits to the dentist for advice or treatment during pregnancy, the mothers’ knowledge in relation to caries, periodontal disease and the possible consequences is insufficient. Unfortunately, mothers do not know that untreated cavities may be associated with the risk of caries in children. Finally, untreated oral infections may become systemic problems during pregnancy and may even contribute to pre-term birth (Lewit and Monheit, 1992). Even in the developed nations, there is a common belief that children do not need early dental visits because they will subsequently lose their baby teeth. In this study, it was found that 18% of the mothers had no idea when their children should visit a dentist for the first time, while more than half believed that their children should first visit a dentist at the age of 3 years. Unfortunately, a considerable portion of mothers (18%) believed that the first visit to the dentist should occur only when the child is in pain. While the common belief many years ago was that the first dental visit should occur at the age of three, today mothers need to be encouraged to bring their child to the dentist before the child‘s first birthday, specifically between 6 and 12 months of age. Mothers’ knowledge about the transmissible nature of caries is important. There are many ways of transmitting S. mutans from the mother’s to the child’s mouth, such as by kissing or when mothers ‘clean’ their children’s pacifiers or taste their children’s food or drink (Berkowitz et al, 1980). Unfortunately, the majority of interviewed mothers had inadequate knowledge about these habits. When mothers were asked whether they cleaned their baby’s pacifiers or tasted the fluid from their baby’s bottle, 35% confirmed such risky behaviours. It has been demonstrated that bottle feeding may contribute to caries, especially ECC. The relationship between bottle usage and high salivary levels of the cariogenic bacteria S. mutans has been reported (Mohan et al, 1998). Surprisingly, even though a considerable number of mothers in
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our study were unemployed and did not send their children to kindergarten, they fed their children with bottles (65%). Unfortunately, maternal knowledge regarding the role of bottle feeding in the occurrence of ECC was generally low (12%). An unfavourable practice involves mothers putting their children to sleep with milk- or juice-filled bottles, which was practiced in 74% of the children. Other authors have also reported this detrimental practice (Kaste and Gift, 1995). More recent evidence suggests that taking a bottle to bed may be a stronger predictor of anterior-tooth ECC patterns than previously believed (Douglass et al, 2001). The findings of Menghini et al (2003), including children from exYugoslavia (a considerable number of those children were from Kosovo), have suggested that all children with caries had similar risk behaviours. The presence of plaque and the use of a night-time bottle proved to be the strongest predictor variables for caries. Frequent drinking of sugared nonmilk drinks, age and no pacifier use were further risk indicators in children of mothers from ex-Yugoslavia living in Switzerland (Menghini et al, 2003). The present results demonstrate that mothers’ knowledge about elementary preventive measures is very low, therefore the clinical consequences are high and manifest as frequent emergency visits of children to the dental clinic. Besides behavioural and motivational recommendations, we propose training the mothers and educators in the ‘lift the lip’ method so they can observe the ECC in early noncavitated stages. According to Drury et al (1999), the diagnosis of noncavitated carious lesions will provide more useful data on the caries process in primary teeth and may aid in understanding the progression of caries during early childhood. The consumption of sweets containing sucrose may be considered an important factor in the occurrence of caries (Marthaler, 1990) and the association between the intake of sucrose and caries has been well established in numerous studies. Even though most of the mothers who were interviewed know that sweets consumption is harmful for their children’s teeth, in reality they do not possess the positive skills/habits to reduce sweets consumption in their children. In this study, a high percentage of the children consumed sweets: over 90% of them consumed sweets at least once/twice a day. Another serious factor is that 69% of the children consumed sweets between meals. In developed countries, advanced preventive programmes focused on reducing the consumption
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of sweets. Data from the literature indicate that only 21% and 45% of children in Finland and Denmark, respectively, consumed sweets once a week (Matilla et al, 2000). The consumption of sweets containing sucrose may be considered an important factor in the occurrence of caries (Rugg-Gunn, 1993). In contrast, other authors have reported that with the correct implementation of preventive and educational measures, there was a reduction in the development of caries, despite continued consumption of sucrose-containing foods (Lingstrom et al, 1993). Mothers’ knowledge and behaviours of oral hygiene are the key components for children’s oral health care. The child imitates parental behaviours, including oral hygiene habits; thus, toothbrushing at an early age depends on maternal knowledge and behaviours. In our study, 38% of the mothers stated that their children did not brush their teeth at all. Only 11% of the interviewed mothers demonstrated proper techniques of toothbrushing. Unfortunately, a relatively low percentage of mothers (24%) stated that toothbrushing should last at least 2 to 3 minutes. The interviewed mothers rarely assisted their children during toothbrushing (5%); very similar results in relation to mothers assisting their children (3%) were found also in Bosnia, a country that is geographically close to Kosovo (Huseinbegović, 2001). In contrast, a study in England found that 60% of children started brushing their teeth from the age of 1 year and presumably, their teeth were initially brushed by their parents (Whittle and Whittle, 1988). Another study in England also reported that in 80% of cases, mothers brushed the teeth of their children (Holt et al, 1996). The importance of fluoridation for the prevention of caries is well established and among all endogenous and exogenous methods, the most effective method is water fluoridation. Studies show that fluoridated drinking water is important in the prevention of caries, for instance, preschool children in Ireland showed a very low mean dmft (0.9), largely because their drinking water was regularly fluoridated (Marthaler et al, 1996). Even though fluoride and antimicrobial agents have a beneficial role in preventing caries, an insignificant number of interviewed mothers stated that they had knowledge regarding fluoride and they did not practice these preventive methods (0%) with their children. Besides fluoride treatments, an antimicrobial treatment option has become a serious consideration for many dental professionals. The
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data from the literature have confirmed the positive antibacterial role of chlorhexidine in the destruction of S. mutans colonies and inhibiting caries (Featherstone, 2004; Zhang et al, 2006).
CONCLUSION The present results show that the level of knowledge about oral health among interviewed mothers is very low to nonexistent. Caries experience of Kosovar preschool children is an important indicator which confirms the role of mothers’ knowledge and their behaviour for oral health. Mothers need to be educated and encouraged that they are a key factor in establishing good oral health habits in their children. Since caries represents a serious public health problem in Kosovo, an overall preventive programme for oral health promotion is needed, including the oral health education of mothers. Involvement of dental professionals and public health institutions for maternal and paediatric oral health education must be implemented immediately.
ACKNOWLEDGEMENTS The authors are most grateful to the mothers and their children for participating in this study and to the staff of Paedodontics Department, School of Dentistry of Prishtina. We thank the foreign NGOs: Medair, Swiss Society of Odontology (SSO) and Dental Health International Netherlands (DHIN) for their support of oral health promotion activities in Kosovo.
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22. Reisine S, Litt M, Tinanoff N. A biopsychosocial model to predict caries in preschool children. Pediatric Dentistry 1994;16:413–418. 23. Rugg-Gunn AJ. Dental caries – the role of dietary sugars. In: Rugg-Gunn AJ (ed). Nutrition and dental health. New York: Oxford University Press, 1993;113–193. 24. Saied-Moallemi Z, Virtanen JI, Ghofranipour F, Murtomma H. Influence of mothers’ oral health knowledge and attitudes on their children’s dental health. Eur Arch Paediatr Dent 2008;9:79–83. 25. Shearer DM, Thomson WM, Broadbent JM, Poulton R. Maternal oral health predicts their children’s caries experience in adulthood. J Dent Res 2011;90:672–677. 26. Silver DH. A comparison of 3-year-olds’ caries experience in 1973, 1981 and 1989 in a Hertfordshire town, related to family behavior and social class. Br Dent J 1992;172: 191–197. 27. Suresh BS, Ravishankar TL, Chaitra TR, Mohapatra AK, Gupta V. Mothers’ knowledge about pre-school child’s oral health. J Indian Soc Pedod Prev Dent 2010; 28:282–287. 28. Tinanoff N, O’Sullivan DM. Early childhood caries: overview and recent findings. Pediatric Dentistry 1997;19: 12–16. 29. US Department of Health and Human Services. A national call to action to promote oral health. NIH publication 03-5303. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2003. 30. US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. NIH publication 00-4713. US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. 31. Whittle JG, Whittle KW. Household income in relation to dental health and dental health behaviors: the use of super profiles. Community Dent Health 1988;15:150–154. 32. Williams NJ, Whittle JG, Gatrell AC. The relationship between socio-demographic characteristics and dental health knowledge and attitudes of parents with young children. Br Dent J 2002;193:651–654. 33. World Health Organization Oral Health Surveys. Basic methods, ed 4. Geneva: WHO, 1987. 34. Zhang Q, van‘t Hof MA, Truin GJ, Bronkhorst EM, van Palenstein Helderman WH. Caries inhibiting effect of chlorhexidine varnish in pits and fissures. J Dent Res 2006;85:469–472.
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Mothers’ Behaviours and Knowledge Related to Caries Experience of Their Children Agim Begzatia/Ariana Bytycib/Kastriot Meqac/Blerta Latifi-Xhemajlid/Merita Berishae
Purpose: Insufficient attention paid by public institutions to primary oral health protection measures has contributed to a poor oral health status in Kosovo, especially in children. Because the oral health promotion activities identified the significant roles of mothers in primary prevention, the aim of this study was to determine the level of knowledge and the behaviour of mothers in connection with the caries experience of their children. Materials and Methods: 664 of the mothers who accompanied their children to dental visits were interviewed and data on maternal knowledge and attitudes towards the oral health of preschool children were collected. The children underwent dental examination and the dmft index was recorded. Results: The mean dmft index in all children was 6.30 ± 3.23. A high prevalence of early childhood caries was recorded. The highest mean dmft was recorded for children whose mothers had finished primary and secondary school (6.41 ± 3.36 and 6.62 ± 2.87, respectively). The mothers displayed insufficient knowledge regarding dental visits, feeding, oral hygiene maintenance and the utilisation of fluoride/antimicrobial agents. Conclusions: The results of this study show that the level of knowledge about oral health among interviewed mothers is very low to nonexistent. Mothers need to be educated and encouraged that they are a key factor in improving the oral health habits of their children. Since caries represents a serious public health problem in Kosovo, an overall preventive programme for oral health promotion is needed, including the oral health education of mothers. Key words: caries experience of preschool children, mothers’ knowledge, oral health education Oral Health Prev Dent 2014;2:133-140
Submitted for publication: 10.07.12; accepted for publication: 26.02.13
doi: 10.3290/j.ohpd.a31667
D
ental caries is one of the most prevalent diseases in children worldwide. The Centers for Disease Control (CDC) and Prevention has reported that caries is perhaps the most prevalent disease
a
Associate Professor and Head of Department, Paedodontics and Preventive Dentistry, School of Dentistry, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
b
Dental Hygienist in Private Practice, Prishtina, Kosovo; Oral Health Promotion Group of Kosovo.
c
Assistant and PhD Candidate, Department of Periodontology and Oral Medicine, School of Dentistry, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
d
Assistant and PhD Student, Department of Paedodontics and Preventive Dentistry, School of Dentistry, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
e
Associate Professor, National Institute of Public Health, Department of Statistics, Medical Faculty, University of Prishtina, Prishtina, Kosovo.
Correspondence: Associate Professor Agim B. Begzati, School of Dentistry, University of Prishtina, Lagja e Spitalit str, NN, 10000 Prishtina, Kosovo. Tel: +377-44-124-092, Fax: +381-38-512-474 Email: [email protected] or [email protected]
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in children (US Department of Health, 2000). Epidemiological data derived from the Oral Health Promotion Group of Kosovo showed a high prevalence of caries among children in Kosovo (89.2% among preschool children and 94.4% among schoolchildren). The mean dmft/DMFT index was 5.6 for preschool children and 4.9 for all schoolchildren (Begzati et al, 2011). A severe category of caries that is very common among children of preschool age is known as early childhood caries (ECC). In a previous study, caries risk factors and the clinical consequences of ECC in preschool children of Kosovo were discussed (Begzati et al, 2010). Drury et al (1999) and Menghini et al (2003) recommended that additional research be conducted on the epidemiology, aetiology and effective prevention of caries in preschool-aged children due to lack of information in this area. The diagnosis of noncavitated carious lesions provides more useful data on the caries process in primary teeth and may aid in understanding the progression of caries during ear-
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ly childhood (Drury et al, 1999). Researchers have attempted to describe the cause, treatment and prevention of caries from a microbiological perspective (Berkowitz, 2003). In addition, there are many social, demographic and behavioural factors such as family income, family status, toothbrushing habits, parental knowledge and maternal educational level (Reisine et al, 1994; Tinanoff and O’Sullivan, 1997) which influence oral health during childhood. It has been suggested that family history has an impact on the outcome of non-genetic factors, e.g. environmental factors, exposures and common behaviours (Shearer et al, 2011). In order to improve the oral health of small children, it is important to convince parents to actively participate in preserving the dental health of their offspring (Menghini et al, 2008). Children under the age of 5 years spend most of their time with mothers; during this time, the earliest childhood routines and habits are acquired. These include healthy behaviours and dietary habits as practiced in the home, which are dependent on the knowledge and behaviour of the parents. Parents’ knowledge and beliefs, which affect oral hygiene and healthy eating habits, thus influence children’s oral health maintenance and outcomes (Suresh et al, 2010). Within the family, the mother’s role has been emphasised in relation to the child’s oral health habits and status. Considering the close interaction between mother and child, the mother’s role is an important resource for the child’s perception and acceptance of attitudes, values and behaviours (Saied-Moallemi et al, 2008). The oral health knowledge of mothers and oral health-related habits (toothbrushing, diet, food choices) are directly associated with the oral health and diet of the children (Suresh et al, 2010; Dye et al, 2011). Mothers with a higher education have better knowledge regarding the oral hygiene practices and the importance of deciduous teeth (Suresh et al, 2010). Children’s dietary habits also vary according to their mothers’ educational level: low-education, low-income families consume foods higher in added sugars (Dye et al, 2011). A study by Williams et al (2002) showed that the caries experience in 3-yearold children was associated with a low level of oral health-related knowledge among mothers. In contrast, the frequent dental visits of mothers with a highschool or university education shows an increase in oral health awareness (Silver, 1992). Based on the complexity of factors related to caries, the role of oral health education is believed to
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be very important, especially for mothers. As provided by dental professionals, counseling of mothers about the oral health of their children increased their knowledge and improved their attitude towards the dental health of their children (Blinkhorn et al, 2003). Thus, the aim of this study was to determine the level of knowledge and the behaviour of the mothers in connection with the caries experience of their children.
MATERIALS AND METHODS Interviewing of mothers In a one-year period at the Department of Paediatric and Preventive Dentistry, School of Dentistry, University of Prishtina, 664 children from 803 first visits of preschool children were selected for examination and at the same time their mothers were interviewed. Children were not included in the study if they were accompanied by someone other than their mother, their mothers refused to be interviewed, were part of group visits or had special needs. This study was approved by the University of Prishtina School of Dentistry’s Ethics Board. All participants completed the informed consent form. The mothers were interviewed to collect data regarding their knowledge of oral hygiene practices, diet and feeding habits, fluoride and use of antimicrobial agents for their children. The mothers were also interviewed about dental visits during pregnancy and their children’s first dental visit. The interviews were conducted in a quiet room using direct communication with the subjects. Regarding the educational levels, mothers were divided into three groups: highschool or university education (14–16 years of education), secondary school education (up to 12 years) and primary school education (up to 8 years).
Dental examination of children All children underwent dental examinations for dental status according to the World Health Organization criteria (WHO, 1987). Children were examined using the light from the dental unit, a dental mirror and a dental probe. A carious lesion was recorded when the carious cavity was clearly evident upon visual inspection of the child sitting up-
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Table 1 Basic characteristics of interviewed mothers Mothers’ age Mothers’ education
N
%
mean ± SD
Primary
188
28
Secondary
394
Highschool or university Total
Table 2
Employment rate
Number of children
Age of children
N
%
mean ± SD
mean ± SD
28.80 ± 5.88
43
23
3.32 ± 1.06
3.90 ± 1.08
59
29.82 ± 4.29
205
52
3.13 ± 1.29
4.56 ± 1.20
82
13
28.20 ± 5.08
49
60
1.82 ± 0.63
3.22 ± 0.93
664
100
29.33 ± 4.92
297
45
3.02 ± 1.25
4.22 ± 1.23
Mean dmft of children according to gender, mother’s education and reason for dental visit
Mean dmft by gender
N
%
Mean dmft ± SD
t-test
F
326
49
6.39 ± 3.26
t = 0.68
M
338
51
6.22 ± 3.19
P > 0.05
Total
664
100
6.30 ± 3.23
1. Primary school
188
28
6.41 ± 3.36
1 vs 2 (t = 0.74) P > 0.05
2. Secondary school
394
59
6.62 ± 2.87
1 vs 3 (t = 4.01) P < 0.001
82
13
4.49 ± 3.24
2 vs 3 (t = 4.89) P 0.05). The dmft index of the children whose mothers had finished highschool or university was significantly lower
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Table 3
Children with ECC (N = 664)
Gender
N
%
Mean dmft ± SD
t-test
f
65
48
11.17 ± 2.66
t = 0.21
m
70
52
11.07 ± 2.82
P > 0.05
135
100
11.04 ± 2.80
Total
Table 5 Children’s habits and mothers’ knowledge regarding oral health practices Children’s daily frequency of toothbrushing
Never
38%
Once
51%
Twice
11%
Children’s daily frequency of sweets consumption Rarely
Table 4 Mothers’ dental visits during pregnancy and children’s first dental visit Mothers’ dental experience during pregnancy Dental visit
N
%
469
71
Yes, for advice
53
8
Other reasons (pain, bleeding gums)
142
21
Total
664
No
P-value
r2 = 433.59 P < 0.0001
100
24%
At least twice a day
67%
Children who consume sweets between meals
69%
Bottle feeding No
15%
Less than 1 year of age
20%
More than 1 year of age
65%
Children who sleep with bottle
74%
Mother knows about negative effects of bottle feeding
12%
Mother ‘tastes’ child’s food
35%
Mother knows about proper tooth brushing technique 40
6
After one year
120
18
r2 = 357.41
After 3 years
384
58
P < 0.0001
Do not know
120
18
Total
664
100
(P 0.05). The dental experience of the children proved to be unpleasant. In 65% of the cases, the mothers stated that children visited the dentist because of toothaches. These children’s mean dmft was 6.69 (SD 3.54). This mean dmft was significantly higher compared with cases involving children seen by a dentist for advice (P < 0.001). The prevalence of ECC was 21% and the mean dmft in children with ECC was 11.04 (SD 2.8). There was no significant difference between the genders (P > 0.05) (Table 3).
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At least once a day
Mother assists or brushes child’s teeth
Children’s first dental visit On eruption
9%
5% 11%
Mothers’ knowledge on toothbrushing duration At least 2 to 3 min
24%
Don’t know
76%
Fluoride or antimicrobial agent utilisation in their children
0%
Mothers’ dental experience during pregnancy shows a significant difference in terms of the reason for the dental visit (P < 0.001) (Table 4). Most of the interviewed mothers (71%) reported that during the pregnancy they did not visit the dentist at all. Only 8% of them visited the dentist for advice, whereas 21% visited the dentist because of pain or gingival bleeding (21%). Significant differences were found for mothers’ responses about when the child’s first dental visit should take place (P < 0.001) (Table 4). More than half (58%) of the mothers reported that the first dental visit should be done after the age of three. The data concerning children’s oral hygiene, sweets consumption and bottle feeding are presented in Table 5. A high percentage of children
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(38%) did not brush their teeth at all and the consumption of sweets was very high. Two-thirds of the children consumed sweets twice or more each day (67%) and unfortunately, 69% of the children reported consuming sweets between meals. Bottle feeding for a duration of more than one year was practiced in 65% of the children. A very high percentage of children (74%) slept with the bottle. Mothers’ knowledge regarding the influence of bottle feeding on ECC occurrence was scarce, with only 12% acknowledging its negative role. Another unhealthy habit was identified, which involved the mothers’ tasting the spoon first to check whether the food was hot before feeding their children. This practice was confirmed by 35% of the mothers. Maternal knowledge and habits on oral health practices are also presented in Table 5. Only 5% of the mothers assisted their children during toothbrushing. The proper technique of toothbrushing was reported by only 11% of the mothers and toothbrushing duration of at least 2 to 3 min was reported by 24% of them. There was an overall absence of fluoride use by the mothers, as they were not aware of the role of this essential element; neither were they informed about any antimicrobial agents.
DISCUSSION Kosovo is a country in southeastern Europe with a population of about 2 million. As a result of the high birth rate, Kosovo’s demographic structure is characterised by a large proportion of youth. In 2008, the publication ‘Women and Men of Kosovo’, reported that 46% of Kosovo’s population was under 18 (KSO, 2008). Nevertheless, public institutions in Kosovo have paid insufficient attention to primary oral healthcare measures, especially for children. As an exception, volunteer activities have been organised by the Oral Health Promotion Group established within the University of Prishtina’s School of Dentistry. The importance of the role of mothers in maintaining good oral health in their children is beyond doubt. The mother’s level of education is quite important, especially in Kosovo, where women are not sufficiently educated. According to the official data, nearly half of all women completed only their primary education (44.9%) while only 7.2% had finished highschool or obtained a university degree. Unfortunately, even in this century, illiteracy exists
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in Kosovo, at a rate of around 6% and the number of illiterate women is almost three times higher than that of men. Demographic data are characterised by a high birth rate (15.7%), equivalent to an average of three children per mother. Social data show low employment rates among women (approximately 60%). Even though the prevalence of women is very high in trade and services such as health or education, oral health education has been mostly ignored (KSO, 2008). These official data regarding the education and employment rate of mothers are essentially identical with the results of the present study. The current results show that mothers’ oral hygiene efforts and their knowledge of oral health protection for their children are largely inadequate. This inadequacy is reflected in the dental status of the children, with a mean dmft of 6.3. The highest mean dmft was recorded for children whose mothers finished primary and secondary school (6.4 and 6.6, respectively), while a lower mean dmft (4.5) was recorded for children whose mothers finished highschool or obtained a university degree. Although mothers with a highschool or university education had more oral health knowledge as evidenced by the lower mean dmft, dmft was still high according to WHO standards. The children’s dental health status was even worse given the high prevalence of ECC (above 21%), with a mean dmft of 11 for these cases. Not surprisingly, nearly two-thirds of all children in this study unfortunately visited the dentist only in the presence of pain. This study focused on maternal levels of knowledge regarding oral health, especially since mothers play crucial roles in educating their children. However, an attempt was also made to increase the awareness of not only mothers but also health professionals regarding the importance of the early prevention of dental and oral diseases in children through pre- and postnatal health education. Health education ought to start during the prenatal period. It consists of regular OB/GYN visits and adequate access to necessary medical care to promote good maternal and paediatric health. Unfortunately, only 8% of the mothers sought advice from their obstetrician regarding oral health protection measures for their future child. Nearly three-quarters of the mothers neglected dental visits during their pregnancies. Even though mothers reported occasional discomfort regarding their oral health, such as gingival bleeding or toothaches, their visits to the dentist were very rare, with only 21% seeking
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help from a dentist. Another factor driving maternal negligence towards their own oral health was the inadequate level of awareness among healthcare personnel, as well as their hesitant attitudes. According to the U.S. Department of Health and Human Services (US Department of Health and Human Services, 2003), improving oral health during pregnancy not only enhances the overall health of women, but also contributes to improved oral health for their children. In keeping with the mothers’ rare visits to the dentist for advice or treatment during pregnancy, the mothers’ knowledge in relation to caries, periodontal disease and the possible consequences is insufficient. Unfortunately, mothers do not know that untreated cavities may be associated with the risk of caries in children. Finally, untreated oral infections may become systemic problems during pregnancy and may even contribute to pre-term birth (Lewit and Monheit, 1992). Even in the developed nations, there is a common belief that children do not need early dental visits because they will subsequently lose their baby teeth. In this study, it was found that 18% of the mothers had no idea when their children should visit a dentist for the first time, while more than half believed that their children should first visit a dentist at the age of 3 years. Unfortunately, a considerable portion of mothers (18%) believed that the first visit to the dentist should occur only when the child is in pain. While the common belief many years ago was that the first dental visit should occur at the age of three, today mothers need to be encouraged to bring their child to the dentist before the child‘s first birthday, specifically between 6 and 12 months of age. Mothers’ knowledge about the transmissible nature of caries is important. There are many ways of transmitting S. mutans from the mother’s to the child’s mouth, such as by kissing or when mothers ‘clean’ their children’s pacifiers or taste their children’s food or drink (Berkowitz et al, 1980). Unfortunately, the majority of interviewed mothers had inadequate knowledge about these habits. When mothers were asked whether they cleaned their baby’s pacifiers or tasted the fluid from their baby’s bottle, 35% confirmed such risky behaviours. It has been demonstrated that bottle feeding may contribute to caries, especially ECC. The relationship between bottle usage and high salivary levels of the cariogenic bacteria S. mutans has been reported (Mohan et al, 1998). Surprisingly, even though a considerable number of mothers in
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our study were unemployed and did not send their children to kindergarten, they fed their children with bottles (65%). Unfortunately, maternal knowledge regarding the role of bottle feeding in the occurrence of ECC was generally low (12%). An unfavourable practice involves mothers putting their children to sleep with milk- or juice-filled bottles, which was practiced in 74% of the children. Other authors have also reported this detrimental practice (Kaste and Gift, 1995). More recent evidence suggests that taking a bottle to bed may be a stronger predictor of anterior-tooth ECC patterns than previously believed (Douglass et al, 2001). The findings of Menghini et al (2003), including children from exYugoslavia (a considerable number of those children were from Kosovo), have suggested that all children with caries had similar risk behaviours. The presence of plaque and the use of a night-time bottle proved to be the strongest predictor variables for caries. Frequent drinking of sugared nonmilk drinks, age and no pacifier use were further risk indicators in children of mothers from ex-Yugoslavia living in Switzerland (Menghini et al, 2003). The present results demonstrate that mothers’ knowledge about elementary preventive measures is very low, therefore the clinical consequences are high and manifest as frequent emergency visits of children to the dental clinic. Besides behavioural and motivational recommendations, we propose training the mothers and educators in the ‘lift the lip’ method so they can observe the ECC in early noncavitated stages. According to Drury et al (1999), the diagnosis of noncavitated carious lesions will provide more useful data on the caries process in primary teeth and may aid in understanding the progression of caries during early childhood. The consumption of sweets containing sucrose may be considered an important factor in the occurrence of caries (Marthaler, 1990) and the association between the intake of sucrose and caries has been well established in numerous studies. Even though most of the mothers who were interviewed know that sweets consumption is harmful for their children’s teeth, in reality they do not possess the positive skills/habits to reduce sweets consumption in their children. In this study, a high percentage of the children consumed sweets: over 90% of them consumed sweets at least once/twice a day. Another serious factor is that 69% of the children consumed sweets between meals. In developed countries, advanced preventive programmes focused on reducing the consumption
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of sweets. Data from the literature indicate that only 21% and 45% of children in Finland and Denmark, respectively, consumed sweets once a week (Matilla et al, 2000). The consumption of sweets containing sucrose may be considered an important factor in the occurrence of caries (Rugg-Gunn, 1993). In contrast, other authors have reported that with the correct implementation of preventive and educational measures, there was a reduction in the development of caries, despite continued consumption of sucrose-containing foods (Lingstrom et al, 1993). Mothers’ knowledge and behaviours of oral hygiene are the key components for children’s oral health care. The child imitates parental behaviours, including oral hygiene habits; thus, toothbrushing at an early age depends on maternal knowledge and behaviours. In our study, 38% of the mothers stated that their children did not brush their teeth at all. Only 11% of the interviewed mothers demonstrated proper techniques of toothbrushing. Unfortunately, a relatively low percentage of mothers (24%) stated that toothbrushing should last at least 2 to 3 minutes. The interviewed mothers rarely assisted their children during toothbrushing (5%); very similar results in relation to mothers assisting their children (3%) were found also in Bosnia, a country that is geographically close to Kosovo (Huseinbegović, 2001). In contrast, a study in England found that 60% of children started brushing their teeth from the age of 1 year and presumably, their teeth were initially brushed by their parents (Whittle and Whittle, 1988). Another study in England also reported that in 80% of cases, mothers brushed the teeth of their children (Holt et al, 1996). The importance of fluoridation for the prevention of caries is well established and among all endogenous and exogenous methods, the most effective method is water fluoridation. Studies show that fluoridated drinking water is important in the prevention of caries, for instance, preschool children in Ireland showed a very low mean dmft (0.9), largely because their drinking water was regularly fluoridated (Marthaler et al, 1996). Even though fluoride and antimicrobial agents have a beneficial role in preventing caries, an insignificant number of interviewed mothers stated that they had knowledge regarding fluoride and they did not practice these preventive methods (0%) with their children. Besides fluoride treatments, an antimicrobial treatment option has become a serious consideration for many dental professionals. The
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data from the literature have confirmed the positive antibacterial role of chlorhexidine in the destruction of S. mutans colonies and inhibiting caries (Featherstone, 2004; Zhang et al, 2006).
CONCLUSION The present results show that the level of knowledge about oral health among interviewed mothers is very low to nonexistent. Caries experience of Kosovar preschool children is an important indicator which confirms the role of mothers’ knowledge and their behaviour for oral health. Mothers need to be educated and encouraged that they are a key factor in establishing good oral health habits in their children. Since caries represents a serious public health problem in Kosovo, an overall preventive programme for oral health promotion is needed, including the oral health education of mothers. Involvement of dental professionals and public health institutions for maternal and paediatric oral health education must be implemented immediately.
ACKNOWLEDGEMENTS The authors are most grateful to the mothers and their children for participating in this study and to the staff of Paedodontics Department, School of Dentistry of Prishtina. We thank the foreign NGOs: Medair, Swiss Society of Odontology (SSO) and Dental Health International Netherlands (DHIN) for their support of oral health promotion activities in Kosovo.
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