Commentary on "mothers'/guardians' knowledge about promoting children's oral health".

* Akpabio A, Klausner CP, Inglehart MR. Mothers'/Guardians' knowledge about promoting children's oral health. Journal of Dental Hygiene, Vol. 82, No. 1, Winter 2008.

Abstract

Introduction: The purpose of this study was a) to explore what mothers know about promoting good oral health in their children and which information they need, and b) to identify whether factors such as age, years of education, and number of children in the family affect their knowledge.

Methods: Data were collected from 105 mothers/guardians (age range: 19 to 54 years) who brought a child to an appointment at a community dental clinic. When provided with a choice, 54 mothers/guardians responded to surveys, and 61 participants asked to be interviewed. The respondents had between 1 and 9 children (mean=2.48).

Results: Only 25.7% of the respondents gave correct answers to a question concerning the age at which children should start seeing a dentist, and only 32.4% correctly answered a question about the age at which their children should have their teeth brushed. However, the majority of mothers (91.4%) knew that a child should not go to bed sucking on a bottle containing milk or juice. The higher the family income was, the more the respondents knew about dental care utilization and oral-health-related behavior. The more years of education the respondents had, the more they knew about the consequences of poor oral health. The more children the mothers had, the more they knew about preventing oral health problems. The more knowledgeable the respondents were about oral health promotion, the more often they brushed and flossed, and the less dental anxiety they had.

Conclusions: Parents and caregivers can play an important role in preventing oral disease in children and should thus be well educated about oral health promotion. These findings point to the importance of focusing educational efforts on educating younger mothers with fewer children and/or less education who come from socio-economically disadvantaged backgrounds.

Keywords: oral health promotion, children, mothers' knowledge, prevention, oral health.

Summary of Key Findings in This Article

Early childhood caries (ECC) is a preventable dental disease that is demonstrated in small children. Dental caries is identified as the most common chronic disease among children. (1) ECC is defined the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. (2) ECC has been identified as a serious public health problem in lower socio-economic populations. In May 2000, the United States Surgeon General, David Satcher, MD, PhD, issued a report on oral health disparities in the United States. The report stated that 80% of dental caries is found in 25% of American children. (2) Research has shown that the pain and disfigurement caused by dental caries affects weight, sleep, learning, self-image and quality of life. (3-9) It is this population that needs to be targeted for oral health promotion initiatives.

The education of mothers or guardians (i.e., caregivers) is an essential aspect of ensuring good oral health for infants and children. Caregivers' awareness of oral health and the prevention of oral disease have an important and lasting impact on children's oral health and health-related behavior. Young children are susceptible to ECC if certain preventive measures are not initiated at an early age. Caregivers must have an oral health awareness that includes understanding the causes of ECC and the methods of prevention if the oral health of their children is to be preserved. These caregivers are primarily responsible for initiating practices that will prevent dental disease. This includes proper self-care practices and dietary habits that prevent dental caries.

The article by Akpabio, Klausner and Inglehart investigated two factors as they relate to oral health awareness by children's caregivers. The two factors included knowledge about the caregiver's role in preserving their children's oral health, and the identification of influencing demographic factors such as the caregiver's age, their level of education, the number of children they cared for, their income level, their oral health care experiences and dental fear and anxiety, and how these factors are related to their knowledge of oral health care of children. By identifying the level of oral health knowledge of caregivers and certain demographic characteristics of caregivers who may lack this knowledge, oral health education initiatives can be directed to those who need it most. An improvement in children's oral health and reduction in ECC may come about through the education of caregivers about the causes and prevention of dental disease.

This study was conducted at the pediatric dental clinic at Mort Children's Health Center (MCHC) located in Flint, Mich. MCHC serves children from low socio-economic backgrounds (200% below the national poverty level) in Genesee County, Michigan. A written survey questionnaire with 20 true/false items addressing oral health promotion for children was used in this study. More than half of the respondents chose to have the survey read to them. (See example interview questions on this page.) There were 105 female caregivers who responded to the survey, varying in age from 19 to 54 years of age. The survey addressed caregivers' knowledge about oral-health-related issues important to the maintenance and preservation of healthy teeth in infants and children (oral-health-related behavior, utilization of dental health care services, dental knowledge and disease prevention, and consequences of poor oral health). The survey identified demographic characteristics of the respondents such as their age, income, education and the number of children that they cared for. Data were also collected on the caregivers' own oral-health-related practices, concerns and experiences, and the survey attempted to assess their dental anxiety and fear.

Caregivers who brought children to MCHC had a good understanding of basic information about oral-health-related issues for infants and children. Findings of this study revealed that caregivers knew that a child should not go to bed sucking a bottle of milk, formula or juice, and that dental pain can keep a child from paying attention at school (91.4% of the respondents). They understood that a child should visit a dentist twice a year (90.5% of the respondents). The caregivers knew that poor dental health could affect a child's general health, keep a child from sleeping through the night, and the fact that a pea-sized amount of toothpaste is all that is needed to brush a child's teeth (87.6% of the respondents). Some of the responses to survey items identified knowledge deficiencies that could lead to the development of dental disease in their children. Of major concern were responses indicating a lack of knowledge about when a child should first visit the dentist. The item stated, "Once a child is two years old they should visit a dentist." Seventy-four percent of the respondents believed that this statement was true. The American Academy of Pediatric Dentists (AAPD) Web site refutes this, saying, "Your child should visit a pediatric dentist when the first tooth appears, or no later than his/her first birthday." (10) Another response of importance related to an item that stated, "When a child is about two years old, a mother should start to brush their teeth." Caregivers identified this item as true 67.6% of the time. The AAPD Web site recommends, "Starting at birth, clean your child's gums with a soft infant toothbrush and water. Remember that most small children do not have the dexterity to brush their teeth effectively. Unless it is advised by your child's pediatric dentist, do not use fluoridated toothpaste until age 2-3." (10) The responses to these two items highlight key knowledge deficiencies among caregivers as it relates to the oral health of young children.

What Are the Implications of this Article for Clinical Practice?

From this study, certain key actions and strategies can be developed and implemented if the oral health of at-risk infants and children is to be successfully addressed by health care providers. These include:

* Primary health care providers who treat pregnant women and who treat infants and children must recognize that caregivers are the first line of defense against the development of oral disease in their children.

* Pregnant women and caregivers of infants and young children who are financially disadvantaged (the average poverty threshold for a family of four in 2005 was $19,971) should be targeted for education regarding oral health promotion for children. (11)

* An article entitled "Anticipatory Guidance in Infant Oral Health" written by Sanchez and Childers, presents a framework of topics identified by AAPD appropriate to be discussed with caregivers about the important components of oral health promotion. (12)

* The education of the health care providers who work with caregivers is imperative if this effort is to be successful.

Health Care Providers' Responsibility

Primary health care providers who work with pregnant women and caregivers of infants and children include dentists, dental hygienists, physicians, nurse practitioners and nurses. They must take this opportunity to disseminate oral health information to these caregivers. Dental hygienists in particular play a crucial role in this regard because, as they educate an individual about their own oral health, it should become a routine practice to include oral health promotion information for children, including unborn children. Gurenlian stresses the important responsibility of the dental hygienist "to provide instruction on oral health care for the infant and growing child" to pregnant women at dental visits, in her commentary about the knowledge and practice behaviors of obstetricians concerning periodontal health and pre-term delivery. (13) It is important to emphasize the role of caregivers of ensuring proper oral health of children for whom they have responsibility. A routine conversation at a health care visit offers the opportunity to inquire about a child's oral health and can lead to oral health promotion education for the caregiver. This contact becomes important since preschool children (ages 2-4) have the lowest rates of dental care of all age groups. (11)

Targeting Caregivers Who Are Financially Disadvantaged

Evidence supports the need for health care providers to direct their efforts to educate caregivers of children of families who are below the national poverty level. Data from 2005 show that of families with incomes below $20,000 and children ages 2-17, only 66% had a dental visit in the past year, compared to 82% of children in families with twice the income. The children at most risk were those ages 2-4, of whom only 43% visited a dentist in the past year. (11) Data also show that 32% of children from families with annual incomes below $20,000 demonstrate untreated caries as compared to 17% of peer children from families with higher incomes. (11)

Providing a Structured Approach to Education of Caregivers

Anticipatory guidance is a proactive developmentally based counseling technique that focuses on the needs of a child at each stage of life. This approach provides the caregiver with health promotion information and preventive measures that will address the health of their children before problems develop. "Although certain risk factors are associated with the development of oral disease in children, it has been difficult to successfully identify infants at greatest risk for oral disease later in life." (12) Current guidelines emphasize primary prevention. Primary prevention is identified as strategies aimed at preventing disease through health promotion and specific activities that protect an individual from disease. (14) According to AAPD guidelines, every child should begin to receive oral health risk assessments by six months of age from a qualified pediatric health care professional. The Caries Risk Assessment Tool provided by the AAPD (available at www.aapd.org/members/referencemanual/pdfs/0203/Caries%20Risk%20Assess.pdf) can be used to determine the relative risk of caries of the patient. (15)

Conclusion

Being more highly educated, having a higher family income, and having more children, are positively correlated with more knowledge regarding oral health behavior and dental care utilization. This study presents data that support the need for early intervention by those health care professionals who work with pregnant women, and caregivers of infants and young children. The United States Healthy People 2010 Objective 21-1a's goal is to "reduce the proportion of young children with dental caries experience in their primary teeth. (16) This is particularly important since recent data from the Centers for Disease Control show a trend in the other direction; i.e., an increase in the incidence of dental caries in primary teeth." Strategies for health care providers to encourage caregivers to promote the oral health of their infants and children include

* educating younger caregivers, pregnant women, first time mothers, and mothers with small children about promoting their children's oral health;

* targeting caregivers who are from lower socio-economic backgrounds;

* informing caregivers about the appropriate time to begin utilization of dental services for children;

* explaining to caregivers how and when to begin to clean their children's teeth;

* motivating caregivers to care for their own teeth, since this will affect the habits of their children; and

* addressing the subject of dental anxiety and dental fear of caregivers when educating them to promote the oral health of their children.

In addition to educating caregivers, dental hygienists and dental hygiene educators must initiate efforts to raise awareness in other health care and public service providers working with this population, and work with these providers to develop strategies to provide oral heath promotion information to pregnant women and caregivers of infants and young children. This includes "antidpatory guidance, behavior modifications (oral hygiene and feeding practices), and the establishment of a 'dental home' by i year of age for children deemed at risk." (15)

References

(1.) Weintraub JA. Prevention of early childhood caries: a public health perspective. Community Dent Oral Epidemiol 1998; 26: 62-6.

(2.) U. S. Department of Health and Human Services Oral health in America: areport of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. NIH publication 00-4713.

(3.) Schechter N. The impact of acute and chronic dental pain on child development. J Southeastern Soc Pediatr Dent 2000; 6(2): 16-7.

(4.) Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992; 14: 302-5.

(5.) Ayhan H, Suskan E, Yildidm S. The effect of nursing or rampant caries on height, body weight, and head circumference. J Clin Pediab- Dent 1996; 20(3): 209- 12.

(6.) O'Sullivan DM, Tinanoff N. The association of early dental caries patterns with cades incidence in preschool children. J Public Health Dent 1996; 56(2): 81- 3.

(7.) Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor decay before age 4 as a risk factor for future dental caries. Pediatr Dent 1997; 19(1): 37-41.

(8.) Filstrup SL, Briskie D, da Fonseca M, et al.: Early childhood caries and quality of life--child and parent perspectives. Pediatr Dent 2003; 25(5), 431-40.

(9.) Ramos-Gomez FJ, Weintraub JA, Gansky SA, et al.: Bacterial, behavioral, environmental factors associated with early childhood caries. J Clin Pediatr Dent 2002; 26(2): 165-72.

(10.) American Academy of Pediatrics, Parent Resource Center, Parent Education Resources, Dental care for your baby. Available at www.aapd.org/publications/brochures/babycare.asp. Accessed Jan 2, 2008.

(11.) Health Care, United States, 2007. National Center for Health Statistics: Department of Health and Human Services Centers for Disease Control and Prevention. Available at www.cdc.gov/nchs/hus.htm. Accessed Jan. 10, 2008.

(12.) Sanchez OM, Childers NK: Anticipatory guidance on infant oral health: rationale and recommendation. American Family Physician 2000; 61: 115-20, 123-4.

(13.) Gurenlian JR: Commentary on "obstetricians' knowledge and practice behaviors concerning periodontal health and preterm delivery and lower birth weight." Access 2007; 21(10): 32-5.

(14.) Mueller-Joseph L, Peterson M: Dental hygiene process of care: diagnosis and planning, 1st ed. Albany: Delmar; 1995.

(15.) American Academy of Pediatrics, Section of Pediatric Dentistry, Policy Statement. Oral health risk assessment timing and establishment of the dental home. Pediatrics 2003; 3(5):1113-6.

(16.) U.S. Department of Health and Human Services: Healthy People 2010. 2000 Volume II. 2nd ed. Washington, DC: U.S. Department of Health and Human Services. Available at www.healthypeople.gov/Document/HTML/Volume2/ 21Oral.htm. Accessed Jan. 16, 2008.

(17.) Titley K: Anticipatory guidance--our role as practitioners (editorial). Oral Health & Dental Practice Management; January 2006. Available at www.oralhealthjournal.com/issues/lSarticle.asp?id=171150Estory_id=12 1027111840&issue=01012006&PC=&RType. Accessed Jan. 12, 2008

(18.) American Association of Pediatric Dentistry Web site. "Dental Home." AAPD Online Resource Center. Available at www.aapd.org/dentalhome/dentalhome.asp. Accessed Jan. 17, 2008.

(19.) World Health Organization Web site. "About WHO." Available at www.euro.who.int/AboutWHO/Policy/20010827_2. Accessed Jan. 2, 2008.

(20.) Journal of Health Promotion Web site. "Definition of health promotion." Available at HYPERLINK "http://www.healthpromotionjournal.com." www.healthpromotionjournal.com. Accessed Jan. 2, 2008. in hamsters. Infect Immun 1994; 62:4356-61.

Examples of Interview Questions for Caregivers and Their Answers

* When should a mother or caregiver begin to clean a baby's gums?

Answer: As soon as possible with a cloth or soft baby brush

* At what age should a caregiver begin to brush a child's teeth?

Answer: When the first tooth erupts

* At what age is a child most likely able to brush their own teeth independently?

Answer: About six years of age depending on dexterity

* How many times a day should a child's teeth be brushed?

Answer: A minimum of two times a day

* When would it be advised to begin flossing a child's teeth?

Answer: Flossing should be done every day once the teeth begin to touch one another.

* At what age should a child begin flossing their teeth independently?

Answer: When they can demonstrate the dexterity to handle the floss 

* How much toothpaste should be placed on a child's brush for brushing his/her teeth?

Answer: A pea-sized amount

* Why is fluoride important to dental health?

Answer: Fluoride strengthens teeth and prevents caries.

* Is the use of a pacifier a concern for the oral health of an infant or child?

Answer: Generally not a problem until the permanent teeth begin to erupt

Glossary of Terms

American Academy of Pediatric Dentistry (AAPD) is the membership organization representing the specialty of pediatric dentistry. The 7,000 members serve as primary care providers for millions of children from infancy through adolescence.

Anticipatory guidance is a proactive, developmentally based counseling technique that focuses on the needs of a child at each stage of life. (17)

Dental home is a term that embraces the concept that a child's oral health care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist. It reflects the AAPD's clinical guidelines and best principles for the proper delivery of oral health care to all children, with a concentration on infant/age-one patients. (18)

Early childhood caries (ECC) is a severe form of tooth decay that affects the primary teeth of young children up to six years of age. It has formerly been known as "nursing bottle syndrome" or "baby bottle mouth."

Health promotion, as defined by the World Health Organization is the process of enabling people to increase control over, and to improve, their health. In the USA, health promotion is much more narrowly conceived as "the science and art of helping people change their lifestyle to move toward a state of optimal health." (19,20)

Mott Children's Health Center (MCHC) located in Flint, Mich., provides services to children and adolescents of Genesee County by providing for their comprehensive health care needs through direct services, indirect services, and advocacy within the context of family and community.

Primary prevention identifies specific practices for the prevention of disease in susceptible individuals or populations. These include health promotion and specific procedures such as fluoridation. Primary prevention is to be distinguished from secondary and tertiary prevention. Secondary prevention diagnoses disease at an early stage, slows the progress of the disease, and prevents complications. Tertiary prevention emphasizes the rehabilitation and the minimalization the effects of the disease. (14)

Christine P. Klausner, RDH, MS, RDA, has completed 32 years of teaching as adjunct dental hygiene faculty at Lansing Community College, Lansing, Mich. For the past six years, she has been a clinical assistant professor at the University of Michigan School of Dentistry, Ann Arbor, Mich. Her course direction and teaching responsibilities include pre-clinical and clinical instruction for dental hygiene students, degree completion dental hygiene students, dental students and graduate students; and continuing education for both dental hygienists and dentists. Her areas of research include clinical research in periodontics and educational research in the use of technology to support learning. She continues to provide patient care on a part-time basis. A recent highlight in her professional career was attending the 2007 ADHA/People to People Citizen Ambassador Program to Poland and Russia as a delegate.

By Christine P. Klausner, RDH, MS