| Abstract|| |
Introduction: Parents' infant and early childhood oral health knowledge is of paramount importance, because oral health behaviours are the exclusive domain of parents during the early years of life. Studies exploring the association between mother's behaviour, oral health literacy and children's oral health outcomes are scarce. Aim: To evaluate the association between mother's behaviour, oral health literacy and children's dental caries experience. Materials and Methods: A cross-sectional study was conducted among one hundred pre-school children aged 2–6 years and their mothers from pre-schools in Bangalore, India. Data regarding their demographics, mother's knowledge, attitude and practice (KAP) was collected through a questionnaire. Mother's oral health literacy was assessed with Rapid Estimate of Adult Literacy in Dentistry-30 (REALD-30) scale. Caries experience of the children was recorded using Decayed Missing Filled Teeth (DMFT) Index. Data was entered into excel sheet and analysed using statistical package for SPSS 22.0. Results: The mean KAP, REALD-30 and DMFT scores were 13.17 ± 4.57, 17.68 ± 5.85, 2.61 ± 2.21, respectively. In this study, REALD-30 score negatively correlated with DMFT score and positively correlated with KAP score. In a linear regression, KAP and REALD-30 scores showed a highly significant association with dental caries. Conclusion: Mother's behaviour and oral health literacy influenced caries experience of the children. Therefore, improving the behaviour and oral health literacy of the mothers is the key to influence child's oral health.
Keywords: Children, early childhood caries, oral health, oral health literacy
|How to cite this article:|
Sowmya K R, Puranik MP, Aparna K S. Association between mother's behaviour, oral health literacy and children's oral health outcomes: A cross-sectional study. Indian J Dent Res 2021;32:147-52
|How to cite this URL:|
Sowmya K R, Puranik MP, Aparna K S. Association between mother's behaviour, oral health literacy and children's oral health outcomes: A cross-sectional study. Indian J Dent Res [serial online] 2021 [cited 2021 Nov 29];32:147-52. Available from: https://www.ijdr.in/text.asp?2021/32/2/147/330860
| Introduction|| |
Healthy teeth are an essential part of children's overall health. Parents' infant and early childhood oral health knowledge is of paramount importance as they play a pivotal role in maintaining their child's oral health. If parents are not aware of the importance and care of their child's primary teeth, they are unlikely to take the appropriate action that may prevent early childhood caries (ECC) or may not seek professional care.,
Parents' literacy is related to other health outcomes among young children and may represent a mutable factor for overcoming dental health disparities. Health literacy is important for all adults, who must be able to read, interpret and understand information pertaining to healthcare. Whereas oral health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions. Poor oral health literacy is a contributor of poor oral health status in an individual and can result in poor health outcome in a community and health inequalities.,
Oral health literacy can be assessed by a variety of tools which include Rapid Estimate of Adult Literacy in Dentistry-30 (REALD-30), Rapid Estimate of Adult Literacy in Dentistry-99 (REALD-99), Test of Functional Health Literacy in Dentistry (TOFHLiD), Oral Health Literacy Instrument (OHLI) and Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALMD). REALD-30 was developed by Lee et al. based on the Rapid Estimate of Adult Literacy in Medicine (REALM), an efficient word recognition tool used to assess health literacy in the medical field. REALD-30 is a dental word recognition instrument which contains 30 common dental words with various degrees of difficulty.
Studies have reported the relationship of the parents' literacy and the child's oral health outcomes,,,,, and their association,,,,,, using REALD-30,,,, and KAP Questionnaire.,,,,,,,,,, Studies exploring the association between mother's oral health literacy and children's oral health outcomes are scarce in Indian context. The study hypothesised that there was an association between mothers' oral health literacy and children's caries experience. The objective of the study was to assess the association of mother's oral health literacy, their knowledge, attitudes and practices, with the dental caries experience of their children.
| Materials and Methods|| |
This cross-sectional study was conducted among pre-school children aged 2–6 years and their mothers from ten pre-schools in Bangalore, India from February to March 2017. Ethical clearance was taken from the Institutional Ethical Committee (No: GDCRI/ACM (2)/PG/Ph.D/5/2016-2017). Permission from the authorities of the respective pre-schools was obtained prior to the study. Informed written consent was obtained from the mothers.
A close-ended structured questionnaire was developed, based on the previous literature., It consisted of 18 questions assessing knowledge (7), attitude (6) and practice (5) of mothers with regard to their children's oral health. Content validity was assessed by the subject experts. Internal consistency (α) was found to be good (0.80). Readability and comprehension were assessed during pilot study. Necessary corrections and modifications were made. To assess oral health literacy, REALD-30 was considered. This scale includes 30 words from the dentistry context arranged in order of increasing difficulty. A pilot study was conducted among 30 pre-school children and their mothers to check the feasibility of the study. Sample size of 100 was considered (100 mother-child pairs) based on the previous literature.
A list of pre-schools was obtained and ten pre-schools were selected randomly. The participants were recruited from the pre-schools based on the eligibility criteria using consecutive sampling technique till the sample size was met. Children aged ≤6 years accompanied by their mothers who could read and understand English were included in the study. Children with conditions that make assessment of oral health status difficult such as restricted mouth opening, systemic conditions which are known to influence oral health were excluded from the study.
Data collection was done in the respective pre-schools during working hours. General information was collected through interview and administration of KAP questionnaire and REALD-30 with the mothers. Mother's oral health literacy was assessed with REALD-30 scale. Mothers were asked to read each word aloud and scored. Mother's behaviour was assessed with the help of knowledge, attitude and practice related questions.
Oral examination of the children was carried out by a single calibrated examiner and recorded by trained personnel. Dental caries experience was assessed using DMFT index based on WHO 2013 criteria. The sufficient numbers of autoclaved instruments were taken for day-to-day examination. Infection control measures were observed throughout the study.
The data was entered into MS excel sheet and was analysed using statistical package for social science (SPSS) version 22.0. Kuppuswamy's income categories were updated using online calculator with Consumer Price Index for Industrial Workers (CPI-IW) being 274 for February 2017. For knowledge and attitude questions, positive responses (yes) were given a score of 1 and No/Don't know was scored as 0 except in case of negative questions where the scores were reversed. For practice questions, positive responses (Very Often/Fairly often) were given a score of 2, 'Occasionally' was scored as 1 and Never/Hardly ever was scored as 0 except in case of negative questions where the scores were reversed. REALD-30 scores were assigned weights: the correct answers were scored as one (1) and wrong answers as zero (0). Total score was calculated for each mother. REALD-30 scores were dichotomized into 0–12 category (low oral health literacy score) and 13–30 category (high oral health literacy score) based on the previous literature.,
Descriptive and inferential statistical analyses were done. Unpaired student t-test was used to find difference in mean scores between continuous variables. Correlation between mother's behaviour, oral health literacy and children's dental caries experience was assessed using Pearson's correlation test. Linear regression analysis was performed with dental caries as dependent variable. Independent variables were age and gender of the child, socioeconomic status, KAP scores and REALD-30 scores. A P value less than 0.05 was considered as significant.
| Results|| |
In this study, mean age of the children was 4.09 ± 0.88 years. Mean age of the mothers was 27.48 ± 3.17 years [Table 1]. Majority of parents of the study belonged to upper lower class (65.0%).
Forty three percent mothers agreed that the problems with milk teeth will affect permanent teeth. More than half of them were of the opinion that the 'risk of getting tooth decay increases with more frequent exposure to sugar in snacks' (61%); 'babies without teeth need mouth cleaning' (51%); 'parents should start cleaning their child's teeth as soon as the first tooth comes in' (53%); 'parents should brush their child's teeth twice a day until the child can brush on his/her own' (65%). Only 19% were aware that fluoride helps in the prevention of tooth decay. Majority of the mothers disagreed that a cavity in a baby tooth should be filled only when it hurts (52%) [Table 2].
|Table 2: Response of study participants (mothers) according to their knowledge n=100 (%)|
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More than half of the mothers agreed that 'it is necessary to take the child for regular dental visits' (59%); 'cleaning of the child's teeth should be done by mothers' (70%); 'it is necessary to clean the child's teeth after having food' (66%); 'good oral health is related to the good general health' (71%); 'healthy teeth are essential for children to chew the food properly' (81%). To the question 'milk teeth do not require good care as it is going to fall anyway', responses of mothers were equivocal [Table 3].
|Table 3: Response of study participants (mothers) according to their attitude n=100 (%)|
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More than half of the mothers 'cleaned/brushed their child's teeth or gums' (89%) and 'used toothpaste when brushing their child's teeth' (94%). Majority of the mothers never/occasionally rinsed their child's mouth after eating/drinking (54%) and used tongue cleaner along with tooth brush and toothpaste (68%). Majority of the mothers never/occasionally gave sugary food items to their child (72%) [Table 4].
|Table 4: Response of study participants (mothers) according to their practice n=100 (%)|
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The pre-school children had a mean DMFT score of 2.61 ± 2.21. Mean DMFT scores among children aged 2–3 years and 4–6 years were 2.37 ± 1.42 and 2.70 ± 2.46, respectively. Gender-wise, mean DMFT scores among males and females were 2.66 ± 1.82 and 2.55 ± 1.60, respectively. There was no statistically significant difference in DMFT according to age (P = 0.50) and gender (P = 0.28) [Table 5].
Majority of the mothers (76%) had high oral health literacy score. Mean REALD-30 scores were 17.68 ± 5.85. Mean REALD-30 scores were 23.56 ± 4.04 among mothers in the age group 20–29 years and 25.77 ± 3.41 among mothers in the age group of 30–35 years. Mean KAP were 17.68 ± 5.85. Mean KAP were 19.04 ± 2.16 among mothers in the age group 20–29 years and 18.77 ± 3.23 among mothers in the age group of 30–35 years. Age wise, there was no statistically significant difference in KAP (P = 0.78) and REALD-30 (P = 0.15) scores [Table 6].
A highly significant moderate positive correlation was observed between REALD-30 and KAP (r = 0.523, P < 0.001). There was a highly significant moderate negative correlation between REALD-30 and DMFT scores (r = -0.552, P < 0.001) and between KAP and DMFT scores (r = -0.500, P < 0.001) [Table 7].
In the linear regression, there was no significant association between dental caries, age (β = 0.167, R2 = 0.028, P = 0.09) and gender of the child (β = -0.083, R2 = 0.031, P = 0.58) and socioeconomic status (β = -0.033, R2 = 0.038, P = 0.38). KAP scores showed a highly significant association with dental caries (β = -0.527, R2 = 0.158, P < 0.001). REALD-30 scores were found to have a significant association with dental caries (β = -0.291, R2 = 0.216, P = 0.006) [Table 8].
|Table 8: Linear regression analysis with dental caries as dependent variable|
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| Discussion|| |
Parents play a vital role in their children's health. Oral health is an essential component of children's well-being and health. Maternal behaviour has a profound role on the oral health of their children. Inadequate oral health literacy of mothers has been associated with high dental caries experience in children and has a negative impact on children's oral health.,,
Early childhood caries is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a pre-school-age child between birth and 71 months of age. In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, one or more cavitated, missing teeth (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitute S-ECC. The aetiology of ECC is multifactorial. ECC is often associated with low socioeconomic status (SES), a poor diet and bad oral health habits.
In this study, mean age of the children was 4.09 ± 0.88 years which is in line with other studies. [1, 2, 6, 8, 10] Mean age of the mothers was 27.48 ± 3.17 years which is comparable with the previous studies., Gender-wise among children, proportion of males was slightly higher than females in this study. Similar observations were made in other studies.,,, Socio-economic factors, together with poorer parental levels of education and income increase likelihood of malnutrition and dental caries. Majority belonged to upper lower class which was similar to one study.
Mothers are decision-makers in their children's healthcare. Mothers' habits and knowledge about oral health has an impact on their children's oral health status. The poor oral health habits of the mothers are often reflected in the children. Children are more prone to caries when parents ignore or pay less attention to milk teeth. Mothers' knowledge, positive attitude toward good dental care and good preventive practices are very essential in the prevention of dental problems.,,,
Less than fifty percent of the mothers had inadequate knowledge about the importance of diseases and treatment of milk teeth and role of fluoride in the prevention of dental caries. Whereas more than half of the mothers were found to have adequate knowledge about the role of sugar in tooth decay and oral hygiene practices. These findings are in line with other studies [1, 2, 3, 7, 9, 11, 12, 14, 16, 17] except for awareness of fluoride which is contrary with one study. Majority of the mothers had positive attitude. They had strong beliefs regarding the role of mothers in child's oral health and the importance of dental visits which was in line with some studies. [1, 2, 8, 10, 12] More than three-fourth of the mothers performed their children's oral hygiene care which was similar to many studies. [1, 2, 8, 11, 12, 15] There was no significant difference in KAP score according to mothers' age.
REALD-30 is a 30-item scale consisting of words chosen from dentistry based on aetiology, anatomy, prevention and treatment. REALD-30 is simple and easy to administer when compared to other oral health literacy instruments like TOFHLiD, OHLI and REALMD. Pre-validated word recognition instrument REALD-30 was used to assess mothers' dental literacy. Mean REALD-30 score was 17.68 ± 5.85 which was similar to few studies.,, Majority of the mothers (76%) had high oral health literacy score.,, Age wise, there was no significant difference in REALD-30 score.
Dental caries is the most prevalent chronic disease of children. Children with poor oral health habits are more likely to develop dental caries when compared with those with favourable habits., The mean DMFT score was 2.61 which was in line with one study (2.9). There was no significant difference in DMFT score according to age and gender.
Highly significant moderate positive correlation was found between KAP and REALD-30 suggesting a relationship between oral health behaviour and oral health literacy. These findings were in accordance with a study. Highly significant moderate negative correlation was found between DMFT, KAP and REALD-30 which was in line with one study. The findings suggest that children born to mothers with poor oral health behaviour and literacy scores had more caries. Linear regression analysis was done with dental caries as outcome variable. There was no association between age and gender of the child, socioeconomic status and dental caries. KAP scores and REALD-30 scores significantly determined the occurrence of dental caries suggesting a relationship of dental caries with age, oral health behaviour and literacy. Similar observations were made in many studies.,,,,,,,,,
The present study has certain limitations. Cross sectional study design did not allow assessment of causality between study variables. Smaller sample size, bias inherent in questionnaire studies such as response bias, social desirability bias may confound the results in this study. Since the questionnaire and REALD-30 were in English, mothers not knowing English were beyond the scope of the study which might affect the generalisability.
Habits and practice developed in pre-school years provide a foundation for oral health condition and utilisation of dental services in adulthood. Parents, especially mothers, should be made aware of the fact that they are the role models for their children and should be encouraged to improve child's dental health habit.
| Conclusion|| |
In the study, there was an association between mother's behaviour, oral health literacy and children's caries experience. Therefore, improving the behaviour and oral health literacy of the mothers might positively influence their children's oral health.
Special thanks to all study participants and pre-schools authorities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. K S Aparna
Senior Lecturer, Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]