Parental knowledge, attitudes and cultural beliefs regarding oral health and dental care of preschool children in an Indian population: a quantitative study.
Abstract: AIM: Preschool children are dependent upon their parents for their dental care. The aim of this study was to assess the knowledge, attitude and beliefs of parents towards oral health and dental care of their children aged 1-4 years in an Indian population. METHODS: Parents of 620 preschool children, who visited Krishna Dental College and Hospital, Ghaziabad, India for dental treatment were recruited into this study and completed a self-administered questionnaire. RESULTS: It was revealed that the lack of knowledge and awareness of importance of the primary teeth, dental fear of the parents and the myths associated with dental treatment, created barriers to early preventive dental care of preschool children. The oral hygiene and feeding practices were found to be disappointing and the knowledge about the essential role of fluoride and transmission of Streptococcus mutans bacteria was found to be limited. The elders in the family, especially grandparents, highly influenced the decisions of the parents regarding dental treatment of their children. CONCLUSIONS: Parents' knowledge, attitudes and beliefs about the importance of dental health need to be improved. Coordinated efforts by paediatricians, paediatric dentists and other health professionals are required to impart dental health education about oral hygiene, feeding practices, importance of the primary dentition and to promote preventive dental programmes.

Key words: Preschool children, parental attitudes, knowledge, cultural beliefs, oral health
Article Type: Report
Subject: Dental care (Demographic aspects)
Dental care (Research)
Dental care (Social aspects)
Dental hygiene (Demographic aspects)
Dental hygiene (Research)
Dental hygiene (Social aspects)
Dental health education (Demographic aspects)
Dental health education (Research)
Parents (Surveys)
Health behavior (Demographic aspects)
Health behavior (Research)
Mouth (Care and treatment)
Mouth (Demographic aspects)
Mouth (Research)
Mouth (Social aspects)
Authors: Chhabra, N.
Chhabra, A.
Pub Date: 04/01/2012
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2012 Source Volume: 13 Source Issue: 2
Topic: Event Code: 310 Science & research; 290 Public affairs Canadian Subject Form: Health behaviour; Health behaviour
Geographic: Geographic Scope: India Geographic Code: 9INDI India
Accession Number: 290066487
Full Text: Introduction

Developed countries have recorded a significant decline in the severity and prevalence of oral diseases among their populations over the last five decades of the twentieth-century [Davies et al., 1997]. The credit goes to the education promotional programs regarding oral hygiene, diet and feeding practices and programs that encourage early access to professional preventive dental care. Unfortunately developing countries, such as India face many challenges in rendering oral health needs of preschool children, especially in rural populations [Pine et al., 2004; Grewal et al., 2007]. Oral health of the preschool children is affected by parental dental knowledge, attitudes, cultural beliefs and awareness about infant diet and feeding practices, oral hygiene habits, preventive regular dental visits, care of primary teeth and concern for oral health [Okada et al., 2002; Wong et al., 2005]. Knowledge and awareness are necessary prerequisites for changes in behaviour, including behaviour related to health and disease prevention [Green and Kreuter, 1999].

There is a paucity of literature available regarding parental knowledge, attitudes and cultural beliefs regarding oral health of their children in developing countries such as India. Moreover, most of those surveys reported in the literature are targeted at school age children due to easy accessibility, which is not possible in preschool children [Holm, 1990]. Consequently, this study was carried out to investigate how the dental health attitudes, knowledge and cultural beliefs of Indian parents affected the oral health of their preschool children and to formulate data for the prospect of future research.

Methods

Study population and sampling method. A quantitative research methodology was used to collect data on parental attitudes, their knowledge towards child dental care and cultural beliefs affecting the dental treatment. The participants were the parents (primary caregivers), of children aged between 1-4 years who reported for dental treatment in the Department of Paedodontics and Preventive Dentistry, Krishna Dental College and Hospital, Ghaziabad, India. The study population lived in both rural and urban communities. A total of 653 parents agreed to participate in the study, whose age ranged between 24-30 years. The parents were requested to complete a comprehensive questionnaire comprising of a small set of pre-selected topics or questions (Table 1) adopted from oral health literature [Peterson et al., 2000; Stenberg et al., 2000] and chosen based on the researcher's knowledge or experience of the issues under study, on the following:

1. Oral hygiene habits (frequency, duration, time and brushing aids used),

2. Role of the parents in the children's oral hygiene and dental education,

3. Diet and feeding patterns of their children,

4. Assessment of parent's knowledge of oral health and dental problems,

5. Parental attitude and opinion towards dentists and dental care,

6. Awareness of the parents regarding dental treatment and regular dental visits,

7. Cultural beliefs of the parents and their families and social influences that affected the parent's decision regarding dental treatment.

Subjects were advised how to respond to each question by choosing one or more responses from a provided list of options, by writing in the response, or performing a combination of the two. The subjects received a full explanation of how to score their responses. The questionnaire was translated into the local language for better understanding by the subjects, and they were asked to approach the investigator for clarification if there were any doubts. The subjects were free to choose more than one answer for the same question, for some items. This explains why the numbers in the frequency columns of the tables in the results section sometimes did not equal the total sample number for those items.

Most of the parents took 30-40 minutes to complete the questionnaire. Positive reinforcement was performed at the end of the interview for the cooperative behaviour of the subjects and gifts such as toothbrushs, toothpaste, floss, etc. were distributed to each participant. The quantitative research study lasted for a period of 24 weeks. Descriptive statistics were obtained and percentage frequency distributions of parental responses to questions were calculated. Study data was analysed using SPSS (version 13.0) (SPSS Inc., Chicago, Ill.).

Results

Out of the total study population of 653 parents, 595 decided to participate immediately. Fifty eight parents indicated that they were interested in receiving more information before deciding to participate. Of these, 25 parents agreed to participate in the project while 33 parents refused to participate and were eliminated from the study. A total of 620 parents returned the completed questionnaires, accounting for a response rate of 94.9 percent. The final study sample included 504 female parents (81.3%) and 116 male parents (18.7%).

Parental knowledge and awareness regarding oral hygiene habits. Results of the parental questionnaire regarding oral hygiene practices revealed that 53.1% of the preschool children were brushing their teeth 32% of the subjects reported the use of toothbrush and toothpaste to clean their children's teeth while 13.7% used finger and toothpaste/powder for oral cleaning. About 1.3% of the subjects described the use of dental floss, 1.0% reported the use of mouthwash, and 1.8% stated that their children were using toothpicks as an extra aid for oral hygiene. Most of the respondents (41.3%) stated that their children brushed their teeth only once daily while 11.8% brushed twice daily or more (Table 2).

Approximately one-half of the parents interviewed said that brushing the teeth of children under the age of two years was not done at all or was performed occasionally. A child of 3-4 years was anticipated to start brushing his or her own. It was astonishing to find that 39.8% of the parents in this study never watched the brushing technique of their children nor gave them any brushing instructions.

Only 36.5% of the subjects stated that they observed and guided their children during brushing while 23.7% reported giving advice on the importance of brushing but did not monitor the children (Table 2).

Parental knowledge and awareness regarding oral and body health. About 65% of the subjects denied the fact that treatment for decayed primary teeth was essential as they believed that primary teeth were not as important as the permanent teeth. Responses recorded in Table 3 reflected that most caregivers did not believe that problems of primary teeth can affect the permanent successors and only 47.6% of the subjects agreed that oral health could lead to general body health problems (Table 3).

Most of the parents (70%) were aware that frequent intake of sweet and sticky foods could cause decay of the teeth whereas the awareness of the consequences of prolonged, frequent bottle feeding and the harm caused by nursing bottles at bed time was lacking in the study population. The role of fluoride in preventing tooth decay was supported by only 30% of the respondents. Parents were largely unaware that bacteria involved in dental caries could be transmitted to their child from them. Less than 10% of subjects agreed to this fact (Table 3).

Parental attitudes towards professional dental care and associated cultural beliefs. Few subjects (approximately 20%) reported that they took their children to the dentist early in childhood exclusively for prevention. Of the respondents 25% emphasised the importance of regular dental visits while 38.5% of parents disagreed with that fact. The awareness that the first dental visit should occur by 12 months of age was present in only 15% of the study population (Table 4).

The main reason for the last dental visit of the children was toothache (40.3%) other factors being tooth decay (13%), swellings (16.5%), regular dental examination (20.1%), deposits and bad mouth odour (5.2%) (Table 4). These results revealed that the most common reason of disliking and not visiting the dentist on a regular basis was fear by the parents regarding dental treatment (55.2%). Other reasons stated were the high cost of treatment (10.3%), difficulty of accessibility to a clinic (8.6%), shortage of time (7.7%), and cultural beliefs associated with dental treatment (15.9%). When parents were asked if social influences affected their decision regarding dental treatment, 59.7% of the parents responded that elders, especially the grandparents, played a crucial role in taking decisions about dental treatment of their grandchildren (Table 4).

Discussion

To our knowledge, this is one of the very few Indian studies presenting the results of a parental questionnaire designed to assess the knowledge, attitudes and cultural beliefs of parents regarding the oral health of their preschool children. It specifically focuses on the relevant risk and protective factors that are likely to have an influence on oral health in this age group of the population. A good understanding of parental knowledge, attitudes, beliefs and awareness regarding oral health is essential for the effectiveness of oral health promotion efforts aimed at improving the dental health of young children. It has been found that the more positive the parent's attitude is towards dentistry, then the better will be the dental health status of their children [Schroth et al., 2007].

This survey found that 41.3% of the children brushed their teeth at least once daily. Over half (39.8%) of the parents believed that children were capable of brushing their own teeth by the age of 3-4 years. This reflects the lack of both parental and child oral health education. It is highly recommended that adults perform or assist brushing for young children under the age of five years as they are only partially able to brush their teeth due to lack of dexterity and cognition needed for adequate cleaning [Mohebbi et al., 2008].

The majority of the parents did not brush the teeth of their children who were under 2 years old because of a lack of awareness. This is consistent with the findings from previous studies [Habibian et al., 2001; Suresh et al., 2010] who found that most of the parents started brushing their children's teeth when all the primary teeth had erupted. It was quite surprising to find that the use of other recommended oral hygiene methods such as dental floss and mouthwash were performed rarely; this could be due to the lack of oral health education and/or the cost of such aids.

Thus dental health education programs that aim to improve oral health practices among a population need to be organised. Parents should be educated that regular tooth cleaning needs to start early in life, as soon as the first primary tooth erupts and dental floss should be used when adjacent teeth are touching, as recommended by the American Academy of Pediatric Dentistry [2011]. Physical demonstration of tooth brushing techniques to the parents and children and the use of salient reinforcers may be more valuable than verbal advice to clean children's teeth.

The response of the parents here in regarding the role of frequent intake of sweets and sticky food products in causing decay was quite encouraging. The results coincided with previous studies [Lin et al., 2001; Suresh et al., 2010]. On the contrary, concerning the awareness of parents about baby bottle use, it was found that more than two-thirds of the parents continued the use of a nursing bottle at night time while the child was asleep. This revealed parental ignorance regarding nursing bottle use and lack of adequate dental education. Similar findings were reported by Hallonsten et al. [1995]. Consequently, dietary advice should be emphasised by dentists and other health professionals in contact with expectant mothers as well as mothers of infants.

Fluoride has a protective action against the development of caries [Davies et al., 2002]. However, it was unfortunate to find that there was a lack of knowledge by the parents regarding the role of fluoride in preventing decay, about the background levels of fluoride in their drinking water and the appropriate use of fluoridated toothpastes. Parents need to be educated about the importance of fluoride and optimal fluoride exposure required for their children.

The practice of kissing their child and sharing foods and utensils by adults has been associated with early infection with Streptococcus mutans in infants [Newbrun, 1992; Sakai et al., 2008]. It was surprising to find that only 9.8% of parents knew about the transmission of cariogenic bacteria from mother to the child, and the fact that it could increase the risk and severity of caries in very young children. The findings were similar to that reported by Sakai et al. [2008]. Education of parents is required to reduce the risk of early transmission of cariogenic bacteria.

It was also found that the lack of knowledge and beliefs about primary teeth created barriers to early preventive dental care in the study population. The majority of parents were not aware of the long-term importance of primary teeth. They believed that primary teeth would remain in the mouth for only a short period of time and would be replaced ultimately. Forty-six percent of the parents responded that there was no connection between the presence of caries in the primary teeth and subsequent caries in the permanent teeth. A quantitative survey of Vietnamese carers of pre-school children in Canada suggested a lack of parental belief in the importance of primary teeth [Harrison and Wong, 2003]. In a study of carers in Saipan, it was reported that the low value attributed to baby teeth was an obstacle to developing effective prevention programs [Riedy et al., 2001].

It was evaluated and clinically correlated that children of the parents who disagreed that the primary teeth were important, were more likely to have EEC. New methods of delivering anticipatory guidance, laying emphasis on the link between oral health and well-being of the body may be more promising in changing prevalent attitudes and behaviours about the primary dentition.

The necessity of regular preventive dental examinations and treatment was not considered to be important by many of the patients unlike in developed countries where initiative is taken by either their parents or dentists. Such an effort on the part of the parents is predominantly missing in Indian children [Grewal and Kaur, 2007]. Similar findings were observed in this study. The findings in this study were similar to that reported by Hilton et al. [2007] who observed that there was low utilisation of preventive dental services by the preschool children as the parents did not recognise that dental problems might exist in their child.

Fear of dental treatment, whether derived from prevailing community beliefs or personal negative dental experiences was found to be high among the study population of parents who negatively influenced the regular dental visits of their children and prevented them from receiving routine dental treatment. Mattila et al. [2000] also reported similar findings in their studies. Milgrom et al. [1988] noted that children with mothers having high levels of personal fear utilised fewer dental services than children of mothers with low fear. Dentists can play an important role in eliminating the fear of parents and children by an empathic approach, retraining the parental negative behaviours due to previous experiences and educating parents about the latest preventive dental techniques that minimise discomfort and pain. Other reasons for not visiting the dentist were cited as high costs of dental care, difficulty of accessibility to dental clinics, shortage of time and cultural beliefs associated with the dental treatment.

This study revealed that there were many myths associated with dental treatment, for example, that extraction of teeth can have a negative impact on vision, scaling of teeth can cause loosening of teeth, treatment under anaesthesia can adversely affect child development and mental capacity, etc. A better understanding of these cultural beliefs may help the dentists explain the objectives, risks and benefits of dental treatment to the parents [Wong et al., 2005].

The results of this study highlighted that family members, especially grandparents exerted a considerable influence on taking dental care decisions by parents, mainly the mothers. Similar results were reported by Mattila et al. [2000] and Wong et al. [2005] in their studies. The suggestions given by the elders were highly respected although paradoxical advice was sometimes given by them, affecting the accessibility to preventive dental care. It was brought to the notice of the investigators that in many families, elders condemned the oral hygiene practices and dietary restrictions imposed on the children by the parents. Dental educational programs aimed at changing attitudes or beliefs that create potential barriers to dental treatment access should not only target the primary carer or parent but should instead provide awareness to the entire family.

The results of this study reveal that multi-disciplinary approaches to improve preschool oral health are needed. Early identification of the high-risk preschool child is indispensable so that appropriate preventive approaches can be implemented, and anticipatory guidance can be used [Winter, 1990]. New methodologies, especially motivational interviewing and the community development approaches for health promotion are promising and need to be explored [Harrison and White, 1997; Weinstein et al., 2004].

Preventive strategies should be emphasised in programs organised for prenatal women and those in preschool and elementary school settings. In addition, dental education about oral hygiene practices, diet counselling, importance of the primary dentition and regular dental visits need to be given [Blinkhorn, 1981; Adair et al., 2004; Finlayson et al., 2005]. Paediatric dentists and paediatricians should also guide and support public campaigns to reach parents lacking in knowledge of oral health care.

This study has limitations. Every population group has variations in beliefs and practices by socio-economic status, education level, religion, etc. Those determinants to a child's oral health were not considered in this study. Also data reported in this study cannot be generalised to the entire Indian population. Further quantitative and qualitative research studies on a larger sample and for a longer period are essential for the better understanding of the knowledge, attitudes and awareness of parents about preschool oral health and the various factors that influence them. Accurate assessment of caregivers' knowledge and perceptions about children's oral health can aid in the planning and implementation of tailored educational and cognitive-behavioural interventions [Finlayson et al., 2005].

Conclusions

There is a need for intensive coordinated efforts by paediatricians, paediatric dentists and other health care professionals required to cultivate and support positive attitudes among parents. Preventive programs in preschools are required to generate awareness among the parents of preventive oral health care, oral hygiene habits, diet and feeding practices and to promote early preventive visits of preschool children. Barriers to attending oral healthcare such as the fear factor of parents, various myths such as cultural beliefs associated with dental treatment and role of an extended family system in negatively influencing the parent's decision regarding oral care, could be minimised by emphasising the importance of oral health and provision of accessible and affordable oral health services at the primary level.

Acknowledgements

The research protocol of the study was reviewed and ethical clearance to conduct the study was obtained from the Krishna College institutional review board. The participants signed written consent forms before being interviewed.

References

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N. Chhabra, Department of Pedodontics, Krishna Dental College, Ghaziabad, Uttar Pradesh, India.

A. Chhabra, Department of Dental Surgery, Safdarjang Hospital, Delhi, India.

Postal address: Dr N. Chhabra, Department of Pedodontics, Krishna Dental College, Ghaziabad, Uttar Pradesh, India.

Email: nidhimahajandr84@gmail.com
Table 1. The questionnaire that was completed by a sample of
parents of the preschool children in india.

1. How often, a day, does your child brush his/her teeth?

2. What does he/she use for cleaning his/her teeth?

3. What is the role played by you in your child's oral hygiene
and dental education?

4. Does brushing the teeth prevent dental problems?

5. Are the primary teeth important?

6. What is the purpose of the first set of teeth?

7. Can problems of primary teeth affect the permanent teeth?

8. How frequently does your child take sweets?

9. Does frequent exposure to sweet and sticky foods affect
dental health?

10. Does prolonged and frequent bottle feeding affect
dental health?

11. Is it fine to put baby to bed with a bottle?

12. Does fluoride prevent the decay of the teeth?

13. Do bacteria causing decay get transmitted from parents
to children?

14. Whether general body health has a relationship to oral
health or not?

15. Does your family care about the teeth as much as any part
of your body?

16. How frequently do you visit your dentist?

17. Whether regular visits to the dentist are necessary or not?

18. What was the reason for the last visit of your child to
the dentist?

19. What treatment(s) did your child require during the last
visit to the dentist?

20. When do you feel is the best time to take your youngest
child to the dentist?

21. What have been some of your personal experiences going
to the dentist?

22. How have your own experience(s) at the dentist influenced
your decision to take your youngest child to the dentist?

23. Are there other people who influence your dental care
decisions taken for your child?

Table 2. Parental knowledge and awareness of regarding
oral hygiene habits (n=620) in a sample of Indian parents.

                                       Frequency    Percentage (%)

Oral hygiene aids used

Toothbrush and paste                      200            32.3
Toothbrush and powder                      19             3.0
Finger and paste/powder                    85            13.7
Datun and wooden sticks                    11             1.8
Mouthwash                                  6              1.0
Dental floss                               8              1.3
None of the above                         291            46.9

Frequency of tooth brushing

Once daily                                256            41.3
Twice daily                                65            10.5
More than twice daily                      8              1.3
Occasionally or never                     291            46.9

Role of parents in supervision and guidance of oral hygiene

Parents observe and guide                 226            36.5
Parents only advise but                   147            23.7
don't monitor
Parents did not bother                    247            39.8

Table 3. Parental knowledge and awareness of regarding oral
and body health (n = 620) in a sample of Indian parents.

                              Frequency            Percentage (%)

Are primary teeth important?
Yes                              194                    31.3
No                               400                    64.5
Don't know                       26                      4.2

Can problems of primary teeth affect the permanent teeth?
Yes                              201                    32.4
No                               286                    46.1
Don't know                       133                    21.5

Does frequent exposure to sweet and sticky foods affect dental health?
Yes                              435                    70.2
No                               151                    24.3
Don't know                       34                      5.5

Does prolonged and frequent bottle feeding affect dental health?
Yes                              162                    26.1
No                               432                    69.6
Don't know                       26                      4.3

Is it fine to put baby to bed with a sweetened milk bottle?
Yes                              373                    60.2
No                               183                    29.5
Don't know                       64                     10.3

Does fluoride prevent tooth decay?
Yes                              187                    30.1
No                               156                    25.2
Don't know                       277                    44.7

Do bacteria causing decay get transmitted from parents to children?
Yes                              61                      9.8
No                               144                    23.2
Don't know                       415                    67.0

Does oral health affect general body health?
Yes                              295                    47.6
No                               188                    30.3
Don't know                       137                    22.1

Table 4. Parental attitudes towards professional dental care and
associated cultural beliefs (n=620)

                                                         Percentage
                                           Frequency        (%)

How frequently do you visit the dentist?

Regularly                                     139           22.4

When having pain or in trouble                327           52.8

Sometimes or never                            154           24.8

Are frequent visits to the dentist important?

Yes                                           156           25.2

No                                            239           38.5

Don't know                                    225           36.3

At what age should the first dental visit of the child be
scheduled?

When the first primary tooth erupts            94           15.2
or before the age of 1 year

When permanent teeth erupt                    302           48.7

Don't know                                    224           36.1

Reason for the last dental visit of your child:

Decay                                          81           13.1

Pain                                          250           40.3

Swelling                                      102           16.5

Deposits and bad odour                         32           5.2

Regular dental check-up                       125           20.1

Other reasons                                  30           4.8

Reasons behind not visiting the dentist:

Fear factor of parents                        342           55.2

High cost of treatment                         64           10.3

Difficulty of accessibility to clinic          53           8.6

Shortage of time                               48           7.7

Any cultural beliefs associated with           99           15.9
dental treatment

No specific reason                             14           2.3

Do you think that your fear factor affects the dental
treatment of your child?

Yes                                           231           37.2

No                                            144           23.3

Don't know                                    245           39.5

Are there other people who influence your dental care
decisions taken for your child?

Yes                                           370           59.7

No                                            250           40.3
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