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Perspectives of Maryland Adults Regarding Caries Prevention Alice M. Horowitz, PhD, Dushanka V. Kleinman, DDS, MscD, Wendy Child, MSc, and Catherine Maybury, MPH
Dental caries (tooth decay) is the most common disease of children, even more common than asthma. This disease has serious health consequences, causes needless suffering, and affects children’s ability to eat, speak, and learn.1 Moreover, when left untreated dental caries can result in death, as was the case with Deamonte Driver, a 12-year-old boy in Prince George’s County, Maryland, who died in 2007.2 Data from the National Health and Nutrition Examination Survey for 1999 to 2004 showed that approximately 23% of children aged 2 to 11 years have untreated dental caries. Black and Hispanic children and those living in families with income less than 100% of the federal poverty level had more untreated decay (27.6%, 33.0% and 32.5%, respectively) than their counterparts.3 Maryland data from the 2011---2012 survey of school children showed that 13.7% of children in kindergarten and third grade had a history of decay in their primary teeth.4 Despite these data, dental caries is preventable. However, many parents and caregivers do not know how to prevent this disease or understand their role in doing so. Because parents are the primary caregivers of young children, their knowledge, understanding, and practices influence their child’s oral health and practices. Several studies have found that parental knowledge and behaviors do have an impact on dental caries among young children.5---7 Plutzer and Spencer7 reported that providing oral health anticipatory guidance to pregnant women who were expecting their first child significantly reduced rates of severe early childhood caries in children aged 20 to 22.5 months. Educational interventions using motivational interviewing techniques have also demonstrated decreases in early childhood caries in children whose average age was 3.5 years.8 Thus, to determine what Maryland adults understand about caries prevention, we conducted a statewide random-sample phone
Objectives. We obtained in-depth information from low-income parents and caregivers of young children about their knowledge and understanding of and practices related to the prevention and control of dental caries (tooth decay). Methods. In 2010, we conducted 4 focus groups in Maryland communities with low-income, English-speaking parents and caregivers who had at least 1 child aged 6 years or younger or who were pregnant. We developed a focus group guide based on findings of a previous statewide random telephone survey of adults with young children. Results. Most participants had limited understanding of and extensive misinformation about how to prevent dental caries. They were confused about the use of juice and its impact on their child’s teeth and had limited understanding of the use of fluorides to prevent caries. Most did not drink tap water and did not give it to their children; rather, they used bottled water. Conclusions. These results and those of the statewide telephone survey strongly suggest the need for educational interventions designed for those with limited levels of education. (Am J Public Health. 2015;105:e58–e64. doi: 10.2105/AJPH.2015.302565)
survey. The results indicated that they have critical gaps in their basic understanding about how to attain and maintain children’s oral health, especially those with lower levels of education or whose children are Medicaid recipients. Respondents were not very knowledgeable about how dental caries can be prevented, they did not know that fluoride prevents cavities, and few had heard of dental sealants, another caries-preventive agent. Moreover, many reported that they neither drank fluoridated tap water nor gave it to their child to drink.9 Thus, we cannot assume that adults have access to and know and act on existing knowledge of evidence-based methods for dental caries prevention and early detection for the benefit of their children.1,9---12 Individuals with low health literacy skills and chronic diseases have less knowledge of their disease and its treatment, fewer self-management skills, and poorer health outcomes than healthliterate individuals.1,13---15 Low health literacy skills affect individuals’ ability to communicate with their health care providers and comprehend educational materials.14,16---19 Low levels of oral health literacy are associated with lower levels of
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oral health knowledge, higher levels of dental caries, higher rates of appointment failure, and fewer dental visits.15,20---23 Given the importance of oral health to overall health and because low oral health literacy can have a negative impact on the oral health of adults and their children, we conducted focus groups with pregnant women, parents, and caregivers who were insured by Medicaid or uninsured. Our objective was to obtain an in-depth understanding of the participants’ knowledge and practices related to preventing tooth decay in children that phone surveys could not reasonably obtain. The focus groups were part of a systematic statewide needs assessment of the oral health literacy of the public and health care providers. We used the Precede---Proceed Model of Health Program Planning and Evaluation to guide the social, epidemiological, behavioral, environmental, and educational assessments.24 These assessments included surveys and focus groups regarding the knowledge, attitudes, and practices of medical and dental providers related to caries prevention and their use of recommended communication skills.
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METHODS In 2010, we conducted 4 focus groups among low-income parents and caregivers who had at least 1 child aged 6 years or younger or who were pregnant. Participants were English-speaking adults (n = 34), including 8 pregnant women expecting their first child, 22 mothers, 2 fathers, and 1 grandfather; 25 participants were African American, 8 were Caucasian, and 1 was Latina. All but 1 participant were uninsured or insured through Medicaid. Informed consent was obtained by having participants review and sign the consent form. Respondents were advised that their participation was entirely voluntary and that they could stop at any time. Only first names were used throughout the sessions. Each participant was compensated $25.00. Staff at 2 elementary schools and 2 family centers serving mainly low-income clientele recruited a convenience sample for the focus groups. We selected these sites on the basis of populations with high rates of dental caries. The location and number of participants in each group were as follows: 2 urban sites, Baltimore (n = 8) and Seat Pleasant (n = 8), and 2 rural sites, Chestertown (n = 8) and Hagerstown (n = 10). Selection criteria, provided by the University of Maryland, included currently pregnant or a parent or primary caregiver for a child aged 6 years or younger, enrolled in or eligible for Medicaid, and English speaking. Flyers provided by the University of Maryland were used at each facility to recruit qualified participants for each focus group. We screened participants for eligibility before the focus groups were conducted. The focus groups were held in the same facilities at which participants were recruited and lasted approximately 90 minutes. All groups were held in areas with fluoridated city water, but 2 communities were surrounded primarily by rural areas with well water. The focus groups were facilitated by a qualitative research consultant with extensive experience conducting health-related focus groups in lowincome communities. A semistructured focus group guide was developed by the principal investigator (A. M. H.) and the focus group facilitator (W. C.) on the basis of the findings of the previous phone survey and knowledge of
and experience in working with low-income populations to prevent dental caries. We modified the guide slightly after the first focus group to make questions clearer to participants. Topics included participants’ history of dental care, understanding of dental caries prevention, experience of taking their children to the dentist, and whether anyone had explained to them how to prevent tooth decay. The data analytic process had several steps. After each session, we discussed its strengths and weaknesses. Each recording was transcribed and printed for review by the principal investigator and facilitator. The facilitator prepared a written summary of each session with selected quotes from the transcription and additional notes taken by a team member. The facilitator manually coded the data using a qualitative content analysis method to extract major themes and quotes relevant to the objectives. The principal investigator and facilitator discussed and agreed on the theme categories. Results are presented by theme.
RESULTS Participants’ comments reinforced the findings of a survey of Maryland adults, indicating that they have a low level of understanding about how to prevent tooth decay.9,12 Three major themes with subthemes emerged: participants’ experiences of going to a dentist, insufficient understanding of what causes tooth decay and how to prevent it, and lack of awareness of the importance of fluoride and sources of fluoride.
Experiences of Going to a Dentist (Theme 1) Many of the focus group participants reported not having had regular professional preventive dental care since at least high school, after generally irregular care before that. It was common to hear “I don’t remember going to the dentist.” Quite a few participants were missing teeth, including participants who appeared to be much younger than 40 years. Comments about having teeth extracted were common, and it seemed as though participants thought that losing teeth at some point was inevitable (see the box on page e60). Participants named numerous barriers to going to the dentist, and many participants made comments
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indicating that they were unaware of how important routine preventive care is and that it could prevent tooth loss (see the box on page e60). Some women knew dental care was especially important during pregnancy. For example, 1 mother reported being pushed by her doctor to go to a dentist when she was pregnant. Comments included “When you’re pregnant, they push you to go. . . . My very first doctor from when I got pregnant just kept saying, ‘Make a dentist appointment,’ and gave me a list of dentists and all this stuff.”
Insufficient Understanding of Tooth Decay Causes and Prevention (Theme 2) Most participants were generally aware of what causes dental caries, but several did not appear to know that tooth decay was something to be concerned about. A variety of causes of tooth decay were mentioned, including not brushing (see the box on page e61). Although some of the causes individuals cited were accurate, no one mentioned bacteria, the potential to transmit caries-causing bacteria to their child, or the greater chance of this occurring if the parent or caregiver had poor oral health. No one mentioned white spots, which are early carious lesions that can be remineralized to prevent cavitation of the tooth. Regarding sweets, participants knew that candy and soda should be limited, but few participants were aware of how detrimental juice is. They reported that they had heard that it was important to cut back on juice, but also reported that the Women, Infants, and Children Supplemental Nutrition Program (WIC) recommended juice as a healthy alternative to soda. Some reported that they had been advised (incorrectly) that watered-down juice is less harmful than full-strength juice. Comments illustrating this confusion included “WIC likes Juicy Juice because that is supposed to be better instead of you giving them Kool-Aid or buying regular juice with all the mixed flavors” and “My dentist said Juicy Juice is good, but when you give it to them when they are little, she said, ‘Mix it with water.’” With regard to specific ways to prevent tooth decay, many participants correctly identified brushing teeth with toothpaste containing fluoride, flossing, and limiting sweets and juices
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Experiences of Going to a Dentist: Baltimore, Seat Pleasant, Chestertown, and Hagerstown, MD Childhood Memories of Dental Visits “I don’t remember the first visit, but I am pretty sure it was bad, so I don’t like to go now . . . . I have a cavity [now]; it bothers me.” “I just remember getting cleanings. I don’t remember much about anything. It was terrible when they go in there and scrape your teeth.” “I don’t remember going to the dentist at all, but I do remember having to get a tooth pulled and being so scared. . . . . I remember falling asleep and looking up and being scared.” “I don’t remember going that much when I was younger. I think I made my first appointment for myself when I turned 18 and got medical insurance. [I haven’t had] any bad experiences, except when I had my tooth pulled.” “I don’t remember going to the dentist at all when I was young. . . . My grandmother raised me and she never took me to the dentist [but] I didn’t eat a lot of candy and stuff anyway.” Adult Experiences “I know I need to get to the dentist, but then I think of the pain. Last year, the lady numbed my tooth and I felt everything, so, no more. I had a bad experience. I would rather feel pain before I go to the dentist.” “I remember as an adult, having to get my teeth scaled. We did one quadrant, and I couldn’t [do] more. It was so painful.” “I don’t go to the dentist because of several bad experiences [when I went for care] at the dental school and I don’t have any money [to go somewhere else]. My first bad experience—I needed my teeth pulled, but they told me I didn’t . . . 3 months later, they broke off while I was eating.” “The only way I’ll go [is if] I have excruciating pain I can’t deal with anymore. Every time I go, I have a tooth pulled.” Lack of Insurance or Specific Coverage for Dental Visits Except During Pregnancy and Difficulty Finding a Dentist who Accepts Medicaid “I have no insurance for dental because Medicaid cut me off when I was 21.” “I don’t have insurance, so it’s hard for me to go. I don’t remember the last time I went.” “I have Medicaid, but they don’t pay dental for me.” “My daughters . . . spend half of their paycheck giving their money to the dentist.” “[I last went] 4 to 5 years ago. I had a tooth pulled. I was supposed to go when I was pregnant and I had insurance to go, through Medical Assistance, but my dentist no longer takes that form of insurance and I have never had another dentist, so I didn’t go.” “That was hard for me—finding a dentist, because insurance doesn’t cover anything unless you are pregnant.” Competing Priorities “I’d rather have my kids go.” “Having four kids, if something’s up with them, I forget about myself.” “It can be hard sometimes. I have four small kids and always have doctor appointments back to back or something going on. That is why I put it off sometimes—getting the [kids] to their appointments is more important.” “I put more energy into my children now than I do for myself. I had a tooth pulled last year but I need to go more often.” “And then I have transportation issues because I don’t have a car.”
(see the box on page e61). However, many participants indicated that they did not necessarily know when or how to teach children to brush or how to supervise children’s brushing. Very few people talked about being given any instruction in or advice about how to brush children’s teeth or at what age to begin. Sometimes the information they reported following was incorrect. One woman reported that her dentist told her to brush her child’s teeth starting at age 3 years. In addition, quite a few parents said they could not make their children brush or that their child did not want to brush and did not seem to recognize how important it is to establish regular, thorough brushing with fluoride. Some people knew about not giving babies and toddlers bottles or sippy cups with milk
and juice, especially at night, and about cleaning babies’ gums. However, these strategies did not seem to be well known. One participant wondered whether tooth decay might be caused by certain types of baby bottle nipples rather than the milk or juice in the bottle (see the box on page e61). Few reported taking children to the dentist regularly as an important part of tooth decay prevention. One mother, who had joint custody of her children aged 2 and 4 years did not know whether they had been to a dentist. Another mother was openly irritated by the idea that children should see a dentist regularly, even though she mentioned that 1 of her children had brown spots on his teeth. In addition, many participants reported taking children to dentists much later than
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recommended and getting conflicting information about whether they needed to go before age 3 years, or even before age 5 years. Almost no one reported having heard the recommendation that infants should be seen by a dentist by age 1 year. Parents and caregivers reported often having difficulty finding a dentist who would see their young children or accept Medicaid—at least any that were located somewhere they could get to—or schedule an appointment sooner than a few months later. In 1 of the groups, when the facilitator asked whether anyone had heard of dental sealants, no one had. All of these parents had a child older than 5 years—the age at which this preventive procedure is recommended. Participants often acknowledged it was not always easy to do the things that they know can
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Insufficient Understanding of What Causes Tooth Decay and How to Prevent It: Baltimore, Seat Pleasant, Chestertown, and Hagerstown, MD Candy and Juice “I think it is because of society—what is fast, what is easy, what you can afford . . . as far as food and what you feed your child for snacks.” “Candy causes tooth decay.” “To prevent tooth decay, cut down on juices for the younger kids and candies—anything that is going to rot their teeth.” Not Supervising Children When They Brush Their Teeth “I made a mistake. My son is 7 and really mature for his age. He likes to do his own stuff and likes to take care of himself, and for a while, I was letting him brush his own teeth; then, he got a cavity.” “I think [tooth decay] comes from parents allowing their kids to brush their teeth on their own.” “My daughter, she was 3, fell off her bike and chipped her tooth and it is easier to get cavities that way. Her front teeth were decayed, and the tooth beside it was getting decayed. I had to take her to Shady Grove where she got four teeth pulled. . . . I just wasn’t that big on her brushing her teeth before she went to bed. Now I see what [not brushing] will do to you—it will ruin your mouth. It is not a game.” Importance of Brushing Teeth “I think you can prevent it because my little brother has perfect teeth and he eats candy, too. My stepmom makes him brush after every meal. I am going to try to do this with my daughter. She doesn’t have any teeth yet.” “I think if you do what the dentist tells you to do to keep teeth healthy, [you can prevent it]. Like I said, I don’t remember going to the dentist, but I have always brushed my teeth and I have never had problems until I was about 30.” “Whatever it takes to get them to brush their teeth, [I do]. We get things from the dentist.” “Aside from candies and soda that we know isn’t [sic] good . . . regular food can cause problems too if you don’t brush immediately.” “Brush after every meal, especially after eating sweets—2 to 3 times a day.” “My 6-year old is good with brushing. I was scared for him flossing—because of blood, but the dentist said it was good for him to floss.” “Two of my kids, ages 6 and 9, are at the age where if they don’t want to do it, they are not going to do it [brushing].” “One of the best ways to prevent decay is to floss because it gets where brushes can’t get.” Other Important Factors “Don’t let kids go to sleep with bottles and sippies [sippy cups] with juice and milk.” “The doctor tells you if they keep the bottle too long, it will rot their teeth out, [but] they don’t go into detail.” “I learned about the gum rubber things. You start with that when they first get teeth coming in because it will help them have healthier teeth. . . . I heard this from my friends who have had kids.” “The pediatrician said to brush her gums, like you’re brushing her teeth [before she gets teeth]. They have these things—the rubber things you put on your finger . . . or you can take a paper towel.” “I really don’t know about tooth decay. I have never even thought about how to prevent it.”
help prevent tooth decay, for example, “My son won’t go to sleep unless he sleeps with a bottle.” Although many participants talked about having had some of their teeth extracted, most participants thought it was possible to prevent tooth decay in their children’s teeth, especially by having them brush.
Lack of Awareness of Importance and Sources of Fluoride (Theme 3) Some of the pregnant women reported that they had never heard of fluoride, but several participants knew it had something to do with preventing cavities. Very few people in the groups seemed to know how important fluoride is or how it works to protect teeth from
decay or remineralize early lesions or white spots (see the box on page e62). Participants were sometimes confused about fluoride and why they were not given more information about it. For example, 1 parent seemed to confuse fluoride with nitrate. One of the pregnant women seemed to think that fluoride is what dentists use to clean teeth—“the pink stuff; it is gritty.” Another reported being asked during a dental visit what kind of water her family drinks. She reported that when she said bottled water, she was told it does not contain fluoride and that as a result her son’s teeth could have reduced enamel. In addition, she reported that another dentist had told her that her son’s teeth were fine and never asked her
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about their drinking water. One mother reported that she had learned about fluoride from her boyfriend’s kids (see the box on page e62). Awareness of or experience with fluoride treatments was minimal. Only 1 person knew about professionally applied fluoride treatments, and she had worked in a dentist’s office. One mother reported that her son’s doctor, not dentist, provided fluoride treatments. She reported that the doctor had said it was “more common” today for doctors to provide fluoride treatments than in the past. This was the only direct reference to fluoride treatment at a doctor’s office, although parents made several comments about having learned some oral health information from pediatricians.
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Lack of Awareness of the Importance of Fluoride and Sources of Fluoride: Baltimore, Seat Pleasant, Chestertown, and Hagerstown, MD Importance of Fluoride “What’s that stuff in the water . . . nitrate? I know that if this stuff is in the water, then it is better for you. I saw a poster at my dentist’s office and it says that Chestertown water is better than Rock Hall water.” “They’ll [the dentist] ask me if I have [fluoride] in my water—but they don’t explain. I’m confused. I know if it’s in your water, you shouldn’t use it in your toothpaste. I’m confused.” “I heard the same. . . . With my brother growing up—he had a tint to his teeth and they told my mom he had a fluoride deficiency. So I always associate [think] you need fluoride for your teeth. As far as them telling you what to use or how much or why—no [they don’t].” “[The brown drops or pills] are called fluoride. . . . I never heard of it until [my boyfriend’s kids] came home with the pills . . . the kids explained to me that this is the reason why most adults have cavities—because they are not getting enough fluoride.” (This mother said it was her child’s pediatrician who confirmed this, and advised her that “if I needed more fluoride, go to the store and put it with water.”) “I remember in elementary school, we did the fluoride thing . . . it’s almost like a mouthwash thing . . . you did it at school. Everyone line up, you drink it, swish it around and rinse in the sink . . . every morning.” “I was excited because it was sweet and tasted like bubble gum.” Drink Tap Water “I drink bottled water, but it has to be flavored. . . . I give my son bottled water because sometimes the water that comes out of the faucet looks and smells a little bleachy and we’re afraid it will hurt him. So we buy Nursery Water for him.” “Bottled water is more cleaner [sic].” “Tap water is nasty.” “I’m not sure [if we have fluoride] and I live in Chestertown.” “I don’t know. It’s well water.” “I live in an apartment complex, so I don’t know.”
Fluoride content had nothing to do with the choice of toothpaste for most participants, although people in different groups said they liked that their toothpaste had tartar control or cavity control. Some participants seemed to think that all adult toothpastes have fluoride. Cost generally drove the choice of toothpaste. In fact, some parents reported that after trying children’s toothpaste to get their kids to brush, they had stopped because it costs more. As 1 parent said, “If it’s on sale, we’ll get that one.” By contrast, a few parents reported purchasing fluoride-free children’s toothpaste to help ensure their children did not get too much fluoride exposure. They reported having heard that fluoride in toothpaste can be poisonous to children if they swallow it: “That’s why you use children’s toothpaste—because if they swallow too much adult toothpaste, it becomes poisonous [from the fluoride].” The participants included both people who reported having well water and others who reported having fluoridated community water. Rural residents were somewhat more likely to report having been asked by their medical
or dental provider about whether their water had fluoride and to have some idea that it was important, either because a dentist had prescribed fluoride drops for their child or because of dental or school-based fluoride varnish treatments. Several participants in each group had no idea whether their drinking water was optimally fluoridated (see the box on this page). Many participants stated that they drank only bottled water because tap water, whether city or well, did not taste good and was not safe. They had limited awareness that except for Nursery Water, bottled water does not contain fluoride. A few moms were aware of Nursery Water with fluoride and reported buying it, sometimes because they had heard fluoride was important. About half of the participants in 1 group reported that they had heard that fluoride protects enamel, but most of them reported drinking only bottled water. However, they also reported buying Nursery Water for their babies. One of the young pregnant women reported that a nurse midwife told her to use Nursery Water because it is sterilized. Two women reported buying Nursery Water, but doing so seemed to be more about avoiding
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tap water than obtaining fluoride. (We should note that Nursery Water is available in gallon containers as either fluoridated or nonfluoridated.) Overall, participants seemed somewhat confused about how much fluoride is necessary or safe, especially with respect to advertising for children’s toothpaste without fluoride, suggesting that nonfluoridated toothpaste is a good thing. They were concerned that fluoride in toothpaste could be harmful, but they understood that fluoride in Nursery Water was good for their children’s health.
DISCUSSION Participants provided a detailed understanding of the knowledge and practices of low-income caregivers of young children regarding caries prevention. Beyond the basics, few people knew about oral health practices such as cleaning babies’ gums, the importance of fluoride, the meaning of white spots, the link between tooth decay and bacteria that can be transmitted by parents and caregivers to babies, the risk of baby bottle tooth decay,
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or the importance of early and regular professional dental care starting around age 1 year. Conflicting information about several of the most important strategies for preventing tooth decay contributed to a great deal of confusion about what parents need to do. Although both the American College of Obstetricians and Gynecologists25 and a recent national consensus statement from an expert panel26 have recommended that pregnant women have oral health care during their pregnancy, few women reported having done so. Dental caries is a transmissible disease, caused by certain types of bacteria that can be transmitted from a mother to her child.27 The higher the levels of bacteria in the mother, the greater the risk she will transmit these bacteria to her child. Thus, it is important to restore (fill) active caries lesions (cavities) before delivery. The oral health status of Maryland adults suggests that many adults have not acquired the knowledge and skills they need to adequately promote good oral health for themselves or their children. For our participants, the absence of Medicaid or other insurance coverage for adult dental care made regular preventive care unavailable. Concomitantly, parents had not been exposed to as much, if any, accurate information or messages about children’s oral health care as they might have had they been able to go to a dentist routinely. The need for dental benefits for adult Medicaid recipients is obvious. We have known how to prevent dental caries for decades, but this knowledge has not been transferred to those most at risk for dental caries—individuals with low education and income. The most effective method for preventing dental caries is through appropriate use of fluorides, and community water fluoridation is considered the most cost-effective way to reduce dental caries. Although more than 97% of central water supplies in Maryland are optimally fluoridated, low-income populations report drinking bottled water (most of which does not contain fluoride) instead of tap water, even if fluoridated tap water is available in their home and community.9 Collectively, the quantitative evidence from the phone survey and the qualitative evidence from these focus groups suggest strongly that we must redouble our efforts to educate the public about how to prevent tooth decay. Because relatively few
science-based educational messages about caries prevention are available for use in community-based dental and medical clinics, organizations such as the American Dental Association, American Dental Hygiene Association, Centers for Disease Control and Prevention, and the National Institute of Dental and Craniofacial Research, which have an interest in preventing oral diseases, should develop, test, and provide messages in a variety of formats. Promoting the consumption of fluoridated tap water should be a priority.
Limitations Limitations of our study include that although all participants met our criteria, the sample was one of convenience and limited to English-speaking adults. Moreover, the majority of participants were women, which limits generalizability. Finally, the study is limited by the number of participants and focus groups. However, this limitation is compensated for by the fact that by the fourth focus group we were not gaining any additional information, which suggests data saturation.
a statewide program to increase oral health literacy and practices that prevent this nearly ubiquitous disease among low-income families. j
About the Authors Alice M. Horowitz is with the Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park. Dushanka V. Kleinman is with the Department of Epidemiology and Biostatics, School of Public Health, University of Maryland. Wendy Child is an independent consultant, College Park, Maryland. Catherine Maybury is with the Office of the Dean, School of Public Health, University of Maryland. Correspondence should be sent to Alice M. Horowitz, Herschel S. Horowitz Center for Health Literacy, Room 2367, School of Public Health, University of Maryland, College Park, MD (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted January 7, 2015.
Contributors A. M. Horowitz conceptualized and designed the study, directed the research, and drafted and revised the article. D. V. Kleinman collaborated on the design and contributed to the refinement of the article. W. Child prepared the focus group guide and facilitated the focus groups. C. Maybury made significant contributions to the refinement of the article.
Acknowledgments This study was funded by the DentaQuest Foundation.
Conclusions The qualitative portion of the statewide assessment provides insight into the lack of understanding of how to prevent dental caries among Maryland adults whose children are insured by Medicaid. Overall, there was extensive misinformation and confusion among participants about how to attain and maintain oral health for their children and for themselves. These results, coupled with those of the statewide survey of Maryland adults, illustrate the need for increased educational interventions to prevent dental caries, especially for those with limited levels of education. Because many low-income individuals see their medical provider more frequently than their dental provider, increasing the number of medical providers who give pregnant women and mothers or caregivers of young children anticipatory guidance about how to prevent dental caries could help increase the oral health literacy of this population and ultimately decrease the rates of dental caries in young children. Findings from both the qualitative and quantitative results are valuable and essential elements to develop
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Human Participant Protection This study was approved by the institutional review board at the University of Maryland, College Park.
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7. Plutzer K, Spencer AJ. Efficacy of an oral health promotion intervention in the prevention of early childhood caries. Community Dent Oral Epidemiol. 2008; 36(4):335---346. 8. Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children. Oneyear findings. J Am Dent Assoc. 2004;135(6):731---738. 9. Horowitz AM, Kleinman DV, Wang MQ. What Maryland adults with young children know and do about preventing dental caries. Am J Public Health. 2013; 103(6):e69---e76. 10. Clovis JB, Horowitz AM, Kleinman DV, Wang MQ, Massey M. Maryland dental hygienists’ knowledge, opinions and practices regarding dental caries prevention and early detection. J Dent Hyg. 2012;86(4):292---305.
25. American College of Obstetricians and Gynecologists Women’s Health Care Physicians, Committee on Health Care for Underserved Women. Committee opinion no. 569: oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122(2 pt 1):417---422. 26. Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center; 2012. 27. Fontana M, Wolff M. Translating the caries management paradigm into practice: challenges and opportunities. J Calif Dent Assoc. 2011;39(10):702---708.
11. Buerlein JK, Horowitz AM, Child WL. Perspectives of Maryland women regarding oral health during pregnancy and early childhood. J Public Health Dent. 2011; 71(2):131---135. 12. Oral health knowledge gap contributes to children’s issues. Available at: http://www.deltadental.com/Public/ NewsMedia/NewsReleaseOralHealthKnowledge GapIssues092009.jsp. Accessed July 23, 2014. 13. Schwartzberg JG, VanGeest JB, Wang CC, Eds. Understanding Health Literacy: Implications for Medicine and Public Health. Atlanta, GA: American Medical Association Press; 2005. 14. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51(3):267---275. 15. Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc. 2007;138(9):1199---1208. 16. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995; 152(9):1423---1433. 17. Ubel PA, Smith DM, Zikmund-Fisher BJ, et al. Testing whether decision aids introduce cognitive biases: results of a randomized trial. Patient Educ Couns. 2010; 80(2):158---163. 18. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication. J Natl Cancer Inst. 2011;103(19):1436---1443. 19. Stacey D, Légaré F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;(1):CD001431. 20. Sabbahi DA, Lawrence HP, Limeback H, Rootman I. Development and evaluation of an oral health literacy instrument for adults. Community Dent Oral Epidemiol. 2009;37(5):451---462. 21. White S, Chen J, Atchinson R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav. 2008;32(3):227---242. 22. Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on children’s oral health outcomes. Pediatrics. 2010;126(1):107---114. 23. Holtzman JS, Atchison KA, Gironda MW, Radbod R, Gornbein J. The association between oral health literacy and failed appointments in adults attending a university‐ based general dental clinic. Community Dent Oral Epidemiol. 2014:42(3)263---270. 24. Green LW, Kreuter MW. Health Program Planning: An Educational and Ecological Approach. 4th ed. New York, NY: McGraw-Hill; 2005.
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Perspectives of Maryland Adults Regarding Caries Prevention Alice M. Horowitz, PhD, Dushanka V. Kleinman, DDS, MscD, Wendy Child, MSc, and Catherine Maybury, MPH
Dental caries (tooth decay) is the most common disease of children, even more common than asthma. This disease has serious health consequences, causes needless suffering, and affects children’s ability to eat, speak, and learn.1 Moreover, when left untreated dental caries can result in death, as was the case with Deamonte Driver, a 12-year-old boy in Prince George’s County, Maryland, who died in 2007.2 Data from the National Health and Nutrition Examination Survey for 1999 to 2004 showed that approximately 23% of children aged 2 to 11 years have untreated dental caries. Black and Hispanic children and those living in families with income less than 100% of the federal poverty level had more untreated decay (27.6%, 33.0% and 32.5%, respectively) than their counterparts.3 Maryland data from the 2011---2012 survey of school children showed that 13.7% of children in kindergarten and third grade had a history of decay in their primary teeth.4 Despite these data, dental caries is preventable. However, many parents and caregivers do not know how to prevent this disease or understand their role in doing so. Because parents are the primary caregivers of young children, their knowledge, understanding, and practices influence their child’s oral health and practices. Several studies have found that parental knowledge and behaviors do have an impact on dental caries among young children.5---7 Plutzer and Spencer7 reported that providing oral health anticipatory guidance to pregnant women who were expecting their first child significantly reduced rates of severe early childhood caries in children aged 20 to 22.5 months. Educational interventions using motivational interviewing techniques have also demonstrated decreases in early childhood caries in children whose average age was 3.5 years.8 Thus, to determine what Maryland adults understand about caries prevention, we conducted a statewide random-sample phone
Objectives. We obtained in-depth information from low-income parents and caregivers of young children about their knowledge and understanding of and practices related to the prevention and control of dental caries (tooth decay). Methods. In 2010, we conducted 4 focus groups in Maryland communities with low-income, English-speaking parents and caregivers who had at least 1 child aged 6 years or younger or who were pregnant. We developed a focus group guide based on findings of a previous statewide random telephone survey of adults with young children. Results. Most participants had limited understanding of and extensive misinformation about how to prevent dental caries. They were confused about the use of juice and its impact on their child’s teeth and had limited understanding of the use of fluorides to prevent caries. Most did not drink tap water and did not give it to their children; rather, they used bottled water. Conclusions. These results and those of the statewide telephone survey strongly suggest the need for educational interventions designed for those with limited levels of education. (Am J Public Health. 2015;105:e58–e64. doi: 10.2105/AJPH.2015.302565)
survey. The results indicated that they have critical gaps in their basic understanding about how to attain and maintain children’s oral health, especially those with lower levels of education or whose children are Medicaid recipients. Respondents were not very knowledgeable about how dental caries can be prevented, they did not know that fluoride prevents cavities, and few had heard of dental sealants, another caries-preventive agent. Moreover, many reported that they neither drank fluoridated tap water nor gave it to their child to drink.9 Thus, we cannot assume that adults have access to and know and act on existing knowledge of evidence-based methods for dental caries prevention and early detection for the benefit of their children.1,9---12 Individuals with low health literacy skills and chronic diseases have less knowledge of their disease and its treatment, fewer self-management skills, and poorer health outcomes than healthliterate individuals.1,13---15 Low health literacy skills affect individuals’ ability to communicate with their health care providers and comprehend educational materials.14,16---19 Low levels of oral health literacy are associated with lower levels of
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oral health knowledge, higher levels of dental caries, higher rates of appointment failure, and fewer dental visits.15,20---23 Given the importance of oral health to overall health and because low oral health literacy can have a negative impact on the oral health of adults and their children, we conducted focus groups with pregnant women, parents, and caregivers who were insured by Medicaid or uninsured. Our objective was to obtain an in-depth understanding of the participants’ knowledge and practices related to preventing tooth decay in children that phone surveys could not reasonably obtain. The focus groups were part of a systematic statewide needs assessment of the oral health literacy of the public and health care providers. We used the Precede---Proceed Model of Health Program Planning and Evaluation to guide the social, epidemiological, behavioral, environmental, and educational assessments.24 These assessments included surveys and focus groups regarding the knowledge, attitudes, and practices of medical and dental providers related to caries prevention and their use of recommended communication skills.
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METHODS In 2010, we conducted 4 focus groups among low-income parents and caregivers who had at least 1 child aged 6 years or younger or who were pregnant. Participants were English-speaking adults (n = 34), including 8 pregnant women expecting their first child, 22 mothers, 2 fathers, and 1 grandfather; 25 participants were African American, 8 were Caucasian, and 1 was Latina. All but 1 participant were uninsured or insured through Medicaid. Informed consent was obtained by having participants review and sign the consent form. Respondents were advised that their participation was entirely voluntary and that they could stop at any time. Only first names were used throughout the sessions. Each participant was compensated $25.00. Staff at 2 elementary schools and 2 family centers serving mainly low-income clientele recruited a convenience sample for the focus groups. We selected these sites on the basis of populations with high rates of dental caries. The location and number of participants in each group were as follows: 2 urban sites, Baltimore (n = 8) and Seat Pleasant (n = 8), and 2 rural sites, Chestertown (n = 8) and Hagerstown (n = 10). Selection criteria, provided by the University of Maryland, included currently pregnant or a parent or primary caregiver for a child aged 6 years or younger, enrolled in or eligible for Medicaid, and English speaking. Flyers provided by the University of Maryland were used at each facility to recruit qualified participants for each focus group. We screened participants for eligibility before the focus groups were conducted. The focus groups were held in the same facilities at which participants were recruited and lasted approximately 90 minutes. All groups were held in areas with fluoridated city water, but 2 communities were surrounded primarily by rural areas with well water. The focus groups were facilitated by a qualitative research consultant with extensive experience conducting health-related focus groups in lowincome communities. A semistructured focus group guide was developed by the principal investigator (A. M. H.) and the focus group facilitator (W. C.) on the basis of the findings of the previous phone survey and knowledge of
and experience in working with low-income populations to prevent dental caries. We modified the guide slightly after the first focus group to make questions clearer to participants. Topics included participants’ history of dental care, understanding of dental caries prevention, experience of taking their children to the dentist, and whether anyone had explained to them how to prevent tooth decay. The data analytic process had several steps. After each session, we discussed its strengths and weaknesses. Each recording was transcribed and printed for review by the principal investigator and facilitator. The facilitator prepared a written summary of each session with selected quotes from the transcription and additional notes taken by a team member. The facilitator manually coded the data using a qualitative content analysis method to extract major themes and quotes relevant to the objectives. The principal investigator and facilitator discussed and agreed on the theme categories. Results are presented by theme.
RESULTS Participants’ comments reinforced the findings of a survey of Maryland adults, indicating that they have a low level of understanding about how to prevent tooth decay.9,12 Three major themes with subthemes emerged: participants’ experiences of going to a dentist, insufficient understanding of what causes tooth decay and how to prevent it, and lack of awareness of the importance of fluoride and sources of fluoride.
Experiences of Going to a Dentist (Theme 1) Many of the focus group participants reported not having had regular professional preventive dental care since at least high school, after generally irregular care before that. It was common to hear “I don’t remember going to the dentist.” Quite a few participants were missing teeth, including participants who appeared to be much younger than 40 years. Comments about having teeth extracted were common, and it seemed as though participants thought that losing teeth at some point was inevitable (see the box on page e60). Participants named numerous barriers to going to the dentist, and many participants made comments
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indicating that they were unaware of how important routine preventive care is and that it could prevent tooth loss (see the box on page e60). Some women knew dental care was especially important during pregnancy. For example, 1 mother reported being pushed by her doctor to go to a dentist when she was pregnant. Comments included “When you’re pregnant, they push you to go. . . . My very first doctor from when I got pregnant just kept saying, ‘Make a dentist appointment,’ and gave me a list of dentists and all this stuff.”
Insufficient Understanding of Tooth Decay Causes and Prevention (Theme 2) Most participants were generally aware of what causes dental caries, but several did not appear to know that tooth decay was something to be concerned about. A variety of causes of tooth decay were mentioned, including not brushing (see the box on page e61). Although some of the causes individuals cited were accurate, no one mentioned bacteria, the potential to transmit caries-causing bacteria to their child, or the greater chance of this occurring if the parent or caregiver had poor oral health. No one mentioned white spots, which are early carious lesions that can be remineralized to prevent cavitation of the tooth. Regarding sweets, participants knew that candy and soda should be limited, but few participants were aware of how detrimental juice is. They reported that they had heard that it was important to cut back on juice, but also reported that the Women, Infants, and Children Supplemental Nutrition Program (WIC) recommended juice as a healthy alternative to soda. Some reported that they had been advised (incorrectly) that watered-down juice is less harmful than full-strength juice. Comments illustrating this confusion included “WIC likes Juicy Juice because that is supposed to be better instead of you giving them Kool-Aid or buying regular juice with all the mixed flavors” and “My dentist said Juicy Juice is good, but when you give it to them when they are little, she said, ‘Mix it with water.’” With regard to specific ways to prevent tooth decay, many participants correctly identified brushing teeth with toothpaste containing fluoride, flossing, and limiting sweets and juices
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Experiences of Going to a Dentist: Baltimore, Seat Pleasant, Chestertown, and Hagerstown, MD Childhood Memories of Dental Visits “I don’t remember the first visit, but I am pretty sure it was bad, so I don’t like to go now . . . . I have a cavity [now]; it bothers me.” “I just remember getting cleanings. I don’t remember much about anything. It was terrible when they go in there and scrape your teeth.” “I don’t remember going to the dentist at all, but I do remember having to get a tooth pulled and being so scared. . . . . I remember falling asleep and looking up and being scared.” “I don’t remember going that much when I was younger. I think I made my first appointment for myself when I turned 18 and got medical insurance. [I haven’t had] any bad experiences, except when I had my tooth pulled.” “I don’t remember going to the dentist at all when I was young. . . . My grandmother raised me and she never took me to the dentist [but] I didn’t eat a lot of candy and stuff anyway.” Adult Experiences “I know I need to get to the dentist, but then I think of the pain. Last year, the lady numbed my tooth and I felt everything, so, no more. I had a bad experience. I would rather feel pain before I go to the dentist.” “I remember as an adult, having to get my teeth scaled. We did one quadrant, and I couldn’t [do] more. It was so painful.” “I don’t go to the dentist because of several bad experiences [when I went for care] at the dental school and I don’t have any money [to go somewhere else]. My first bad experience—I needed my teeth pulled, but they told me I didn’t . . . 3 months later, they broke off while I was eating.” “The only way I’ll go [is if] I have excruciating pain I can’t deal with anymore. Every time I go, I have a tooth pulled.” Lack of Insurance or Specific Coverage for Dental Visits Except During Pregnancy and Difficulty Finding a Dentist who Accepts Medicaid “I have no insurance for dental because Medicaid cut me off when I was 21.” “I don’t have insurance, so it’s hard for me to go. I don’t remember the last time I went.” “I have Medicaid, but they don’t pay dental for me.” “My daughters . . . spend half of their paycheck giving their money to the dentist.” “[I last went] 4 to 5 years ago. I had a tooth pulled. I was supposed to go when I was pregnant and I had insurance to go, through Medical Assistance, but my dentist no longer takes that form of insurance and I have never had another dentist, so I didn’t go.” “That was hard for me—finding a dentist, because insurance doesn’t cover anything unless you are pregnant.” Competing Priorities “I’d rather have my kids go.” “Having four kids, if something’s up with them, I forget about myself.” “It can be hard sometimes. I have four small kids and always have doctor appointments back to back or something going on. That is why I put it off sometimes—getting the [kids] to their appointments is more important.” “I put more energy into my children now than I do for myself. I had a tooth pulled last year but I need to go more often.” “And then I have transportation issues because I don’t have a car.”
(see the box on page e61). However, many participants indicated that they did not necessarily know when or how to teach children to brush or how to supervise children’s brushing. Very few people talked about being given any instruction in or advice about how to brush children’s teeth or at what age to begin. Sometimes the information they reported following was incorrect. One woman reported that her dentist told her to brush her child’s teeth starting at age 3 years. In addition, quite a few parents said they could not make their children brush or that their child did not want to brush and did not seem to recognize how important it is to establish regular, thorough brushing with fluoride. Some people knew about not giving babies and toddlers bottles or sippy cups with milk
and juice, especially at night, and about cleaning babies’ gums. However, these strategies did not seem to be well known. One participant wondered whether tooth decay might be caused by certain types of baby bottle nipples rather than the milk or juice in the bottle (see the box on page e61). Few reported taking children to the dentist regularly as an important part of tooth decay prevention. One mother, who had joint custody of her children aged 2 and 4 years did not know whether they had been to a dentist. Another mother was openly irritated by the idea that children should see a dentist regularly, even though she mentioned that 1 of her children had brown spots on his teeth. In addition, many participants reported taking children to dentists much later than
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recommended and getting conflicting information about whether they needed to go before age 3 years, or even before age 5 years. Almost no one reported having heard the recommendation that infants should be seen by a dentist by age 1 year. Parents and caregivers reported often having difficulty finding a dentist who would see their young children or accept Medicaid—at least any that were located somewhere they could get to—or schedule an appointment sooner than a few months later. In 1 of the groups, when the facilitator asked whether anyone had heard of dental sealants, no one had. All of these parents had a child older than 5 years—the age at which this preventive procedure is recommended. Participants often acknowledged it was not always easy to do the things that they know can
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Insufficient Understanding of What Causes Tooth Decay and How to Prevent It: Baltimore, Seat Pleasant, Chestertown, and Hagerstown, MD Candy and Juice “I think it is because of society—what is fast, what is easy, what you can afford . . . as far as food and what you feed your child for snacks.” “Candy causes tooth decay.” “To prevent tooth decay, cut down on juices for the younger kids and candies—anything that is going to rot their teeth.” Not Supervising Children When They Brush Their Teeth “I made a mistake. My son is 7 and really mature for his age. He likes to do his own stuff and likes to take care of himself, and for a while, I was letting him brush his own teeth; then, he got a cavity.” “I think [tooth decay] comes from parents allowing their kids to brush their teeth on their own.” “My daughter, she was 3, fell off her bike and chipped her tooth and it is easier to get cavities that way. Her front teeth were decayed, and the tooth beside it was getting decayed. I had to take her to Shady Grove where she got four teeth pulled. . . . I just wasn’t that big on her brushing her teeth before she went to bed. Now I see what [not brushing] will do to you—it will ruin your mouth. It is not a game.” Importance of Brushing Teeth “I think you can prevent it because my little brother has perfect teeth and he eats candy, too. My stepmom makes him brush after every meal. I am going to try to do this with my daughter. She doesn’t have any teeth yet.” “I think if you do what the dentist tells you to do to keep teeth healthy, [you can prevent it]. Like I said, I don’t remember going to the dentist, but I have always brushed my teeth and I have never had problems until I was about 30.” “Whatever it takes to get them to brush their teeth, [I do]. We get things from the dentist.” “Aside from candies and soda that we know isn’t [sic] good . . . regular food can cause problems too if you don’t brush immediately.” “Brush after every meal, especially after eating sweets—2 to 3 times a day.” “My 6-year old is good with brushing. I was scared for him flossing—because of blood, but the dentist said it was good for him to floss.” “Two of my kids, ages 6 and 9, are at the age where if they don’t want to do it, they are not going to do it [brushing].” “One of the best ways to prevent decay is to floss because it gets where brushes can’t get.” Other Important Factors “Don’t let kids go to sleep with bottles and sippies [sippy cups] with juice and milk.” “The doctor tells you if they keep the bottle too long, it will rot their teeth out, [but] they don’t go into detail.” “I learned about the gum rubber things. You start with that when they first get teeth coming in because it will help them have healthier teeth. . . . I heard this from my friends who have had kids.” “The pediatrician said to brush her gums, like you’re brushing her teeth [before she gets teeth]. They have these things—the rubber things you put on your finger . . . or you can take a paper towel.” “I really don’t know about tooth decay. I have never even thought about how to prevent it.”
help prevent tooth decay, for example, “My son won’t go to sleep unless he sleeps with a bottle.” Although many participants talked about having had some of their teeth extracted, most participants thought it was possible to prevent tooth decay in their children’s teeth, especially by having them brush.
Lack of Awareness of Importance and Sources of Fluoride (Theme 3) Some of the pregnant women reported that they had never heard of fluoride, but several participants knew it had something to do with preventing cavities. Very few people in the groups seemed to know how important fluoride is or how it works to protect teeth from
decay or remineralize early lesions or white spots (see the box on page e62). Participants were sometimes confused about fluoride and why they were not given more information about it. For example, 1 parent seemed to confuse fluoride with nitrate. One of the pregnant women seemed to think that fluoride is what dentists use to clean teeth—“the pink stuff; it is gritty.” Another reported being asked during a dental visit what kind of water her family drinks. She reported that when she said bottled water, she was told it does not contain fluoride and that as a result her son’s teeth could have reduced enamel. In addition, she reported that another dentist had told her that her son’s teeth were fine and never asked her
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about their drinking water. One mother reported that she had learned about fluoride from her boyfriend’s kids (see the box on page e62). Awareness of or experience with fluoride treatments was minimal. Only 1 person knew about professionally applied fluoride treatments, and she had worked in a dentist’s office. One mother reported that her son’s doctor, not dentist, provided fluoride treatments. She reported that the doctor had said it was “more common” today for doctors to provide fluoride treatments than in the past. This was the only direct reference to fluoride treatment at a doctor’s office, although parents made several comments about having learned some oral health information from pediatricians.
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Lack of Awareness of the Importance of Fluoride and Sources of Fluoride: Baltimore, Seat Pleasant, Chestertown, and Hagerstown, MD Importance of Fluoride “What’s that stuff in the water . . . nitrate? I know that if this stuff is in the water, then it is better for you. I saw a poster at my dentist’s office and it says that Chestertown water is better than Rock Hall water.” “They’ll [the dentist] ask me if I have [fluoride] in my water—but they don’t explain. I’m confused. I know if it’s in your water, you shouldn’t use it in your toothpaste. I’m confused.” “I heard the same. . . . With my brother growing up—he had a tint to his teeth and they told my mom he had a fluoride deficiency. So I always associate [think] you need fluoride for your teeth. As far as them telling you what to use or how much or why—no [they don’t].” “[The brown drops or pills] are called fluoride. . . . I never heard of it until [my boyfriend’s kids] came home with the pills . . . the kids explained to me that this is the reason why most adults have cavities—because they are not getting enough fluoride.” (This mother said it was her child’s pediatrician who confirmed this, and advised her that “if I needed more fluoride, go to the store and put it with water.”) “I remember in elementary school, we did the fluoride thing . . . it’s almost like a mouthwash thing . . . you did it at school. Everyone line up, you drink it, swish it around and rinse in the sink . . . every morning.” “I was excited because it was sweet and tasted like bubble gum.” Drink Tap Water “I drink bottled water, but it has to be flavored. . . . I give my son bottled water because sometimes the water that comes out of the faucet looks and smells a little bleachy and we’re afraid it will hurt him. So we buy Nursery Water for him.” “Bottled water is more cleaner [sic].” “Tap water is nasty.” “I’m not sure [if we have fluoride] and I live in Chestertown.” “I don’t know. It’s well water.” “I live in an apartment complex, so I don’t know.”
Fluoride content had nothing to do with the choice of toothpaste for most participants, although people in different groups said they liked that their toothpaste had tartar control or cavity control. Some participants seemed to think that all adult toothpastes have fluoride. Cost generally drove the choice of toothpaste. In fact, some parents reported that after trying children’s toothpaste to get their kids to brush, they had stopped because it costs more. As 1 parent said, “If it’s on sale, we’ll get that one.” By contrast, a few parents reported purchasing fluoride-free children’s toothpaste to help ensure their children did not get too much fluoride exposure. They reported having heard that fluoride in toothpaste can be poisonous to children if they swallow it: “That’s why you use children’s toothpaste—because if they swallow too much adult toothpaste, it becomes poisonous [from the fluoride].” The participants included both people who reported having well water and others who reported having fluoridated community water. Rural residents were somewhat more likely to report having been asked by their medical
or dental provider about whether their water had fluoride and to have some idea that it was important, either because a dentist had prescribed fluoride drops for their child or because of dental or school-based fluoride varnish treatments. Several participants in each group had no idea whether their drinking water was optimally fluoridated (see the box on this page). Many participants stated that they drank only bottled water because tap water, whether city or well, did not taste good and was not safe. They had limited awareness that except for Nursery Water, bottled water does not contain fluoride. A few moms were aware of Nursery Water with fluoride and reported buying it, sometimes because they had heard fluoride was important. About half of the participants in 1 group reported that they had heard that fluoride protects enamel, but most of them reported drinking only bottled water. However, they also reported buying Nursery Water for their babies. One of the young pregnant women reported that a nurse midwife told her to use Nursery Water because it is sterilized. Two women reported buying Nursery Water, but doing so seemed to be more about avoiding
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tap water than obtaining fluoride. (We should note that Nursery Water is available in gallon containers as either fluoridated or nonfluoridated.) Overall, participants seemed somewhat confused about how much fluoride is necessary or safe, especially with respect to advertising for children’s toothpaste without fluoride, suggesting that nonfluoridated toothpaste is a good thing. They were concerned that fluoride in toothpaste could be harmful, but they understood that fluoride in Nursery Water was good for their children’s health.
DISCUSSION Participants provided a detailed understanding of the knowledge and practices of low-income caregivers of young children regarding caries prevention. Beyond the basics, few people knew about oral health practices such as cleaning babies’ gums, the importance of fluoride, the meaning of white spots, the link between tooth decay and bacteria that can be transmitted by parents and caregivers to babies, the risk of baby bottle tooth decay,
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or the importance of early and regular professional dental care starting around age 1 year. Conflicting information about several of the most important strategies for preventing tooth decay contributed to a great deal of confusion about what parents need to do. Although both the American College of Obstetricians and Gynecologists25 and a recent national consensus statement from an expert panel26 have recommended that pregnant women have oral health care during their pregnancy, few women reported having done so. Dental caries is a transmissible disease, caused by certain types of bacteria that can be transmitted from a mother to her child.27 The higher the levels of bacteria in the mother, the greater the risk she will transmit these bacteria to her child. Thus, it is important to restore (fill) active caries lesions (cavities) before delivery. The oral health status of Maryland adults suggests that many adults have not acquired the knowledge and skills they need to adequately promote good oral health for themselves or their children. For our participants, the absence of Medicaid or other insurance coverage for adult dental care made regular preventive care unavailable. Concomitantly, parents had not been exposed to as much, if any, accurate information or messages about children’s oral health care as they might have had they been able to go to a dentist routinely. The need for dental benefits for adult Medicaid recipients is obvious. We have known how to prevent dental caries for decades, but this knowledge has not been transferred to those most at risk for dental caries—individuals with low education and income. The most effective method for preventing dental caries is through appropriate use of fluorides, and community water fluoridation is considered the most cost-effective way to reduce dental caries. Although more than 97% of central water supplies in Maryland are optimally fluoridated, low-income populations report drinking bottled water (most of which does not contain fluoride) instead of tap water, even if fluoridated tap water is available in their home and community.9 Collectively, the quantitative evidence from the phone survey and the qualitative evidence from these focus groups suggest strongly that we must redouble our efforts to educate the public about how to prevent tooth decay. Because relatively few
science-based educational messages about caries prevention are available for use in community-based dental and medical clinics, organizations such as the American Dental Association, American Dental Hygiene Association, Centers for Disease Control and Prevention, and the National Institute of Dental and Craniofacial Research, which have an interest in preventing oral diseases, should develop, test, and provide messages in a variety of formats. Promoting the consumption of fluoridated tap water should be a priority.
Limitations Limitations of our study include that although all participants met our criteria, the sample was one of convenience and limited to English-speaking adults. Moreover, the majority of participants were women, which limits generalizability. Finally, the study is limited by the number of participants and focus groups. However, this limitation is compensated for by the fact that by the fourth focus group we were not gaining any additional information, which suggests data saturation.
a statewide program to increase oral health literacy and practices that prevent this nearly ubiquitous disease among low-income families. j
About the Authors Alice M. Horowitz is with the Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park. Dushanka V. Kleinman is with the Department of Epidemiology and Biostatics, School of Public Health, University of Maryland. Wendy Child is an independent consultant, College Park, Maryland. Catherine Maybury is with the Office of the Dean, School of Public Health, University of Maryland. Correspondence should be sent to Alice M. Horowitz, Herschel S. Horowitz Center for Health Literacy, Room 2367, School of Public Health, University of Maryland, College Park, MD (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted January 7, 2015.
Contributors A. M. Horowitz conceptualized and designed the study, directed the research, and drafted and revised the article. D. V. Kleinman collaborated on the design and contributed to the refinement of the article. W. Child prepared the focus group guide and facilitated the focus groups. C. Maybury made significant contributions to the refinement of the article.
Acknowledgments This study was funded by the DentaQuest Foundation.
Conclusions The qualitative portion of the statewide assessment provides insight into the lack of understanding of how to prevent dental caries among Maryland adults whose children are insured by Medicaid. Overall, there was extensive misinformation and confusion among participants about how to attain and maintain oral health for their children and for themselves. These results, coupled with those of the statewide survey of Maryland adults, illustrate the need for increased educational interventions to prevent dental caries, especially for those with limited levels of education. Because many low-income individuals see their medical provider more frequently than their dental provider, increasing the number of medical providers who give pregnant women and mothers or caregivers of young children anticipatory guidance about how to prevent dental caries could help increase the oral health literacy of this population and ultimately decrease the rates of dental caries in young children. Findings from both the qualitative and quantitative results are valuable and essential elements to develop
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Human Participant Protection This study was approved by the institutional review board at the University of Maryland, College Park.
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