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Parental knowledge about urban preschool children's oral health risk.

Dental caries, or tooth decay, is one of the most prevalent and significant pediatric health problems in the United States (United States Department of Health and Human Services [DHHS], 2000). More than one-fourth of children between the ages of two and five years experience early childhood caries before entering kindergarten, and by age 19, 68% of youth have experienced tooth decay in permanent teeth (National Conference of State Legislatures, 2012). Minorities are disproportionately affected by early childhood caries in the United States (American Academy of Pediatric Dentists [AAPD], 2014). Among three--to five-year-old children, the prevalence of untreated caries was significantly higher for non-Hispanic black children (19.3%) compared with non-Hispanic white children (11.3%) (Dye, Li, & Thornton-Evans, 2012). National studies show Mexican-American children have the highest percentage of untreated caries compared with other ethnic/racial groups (Dye et al., 2012).

Dental caries leads to a variety of problems, such as oral pain, excessive school absenteeism, difficulty concentrating, poor appearance, and poor oral health as an adult (Centers for Disease Control and Prevention [CDC], 2011). An objective of Healthy People 2020 is to reduce the proportion of children who have dental caries and untreated decay (Office of Disease Prevention and Health Promotion, 2015). The AAPD (2014) recommends that parents receive better education about children's primary teeth and oral hygiene to minimize or eliminate dental disease. Studies have shown that parental knowledge of oral health has a significant influence on children's dental caries, and there is an association between lack of parental knowledge and dental caries among children (Isong, Luff, Perrin, Winickoff, & Ng, 2012; Naidu & Davis, 2008).

According to Bandura's social cognitive theory, overt behaviors of significant others represent an important source of social influence (Bandura, 1986). It stands to reason that if parents are knowledgeable about oral health, they can positively influence their child's oral health behaviors. Therefore, assessment of parental knowledge regarding children's oral health is essential prior to developing an appropriate educational program for the target population. The purpose of this study was to explore parents' knowledge of preschool children's oral health risk factors. Findings from this study will illuminate the knowledge gaps in parents of preschoolers aged between two and five years who reside in New Jersey. It is anticipated that this knowledge will assist pediatric nurses and others who work with preschoolers in developing evidence-based, nurse-led community oral health education program for parents.

Literature Review

Parental knowledge and attitudes have a significant influence on children's dental caries (Isong et al., 2012); however, studies have reported that parents lack knowledge about children's oral health (Begzati, Bytyci, Meqa, Latifi-Xhemajli, & Berisha, 2014; Chu, Ho, & Lo, 2012; Gussy, Waters, Riggs, Lo, & Kilpatrick, 2008; Prabhu et al., 2013). Prabhu et al. (2013) reported that parents/guardians of preschool children had poor knowledge pertaining to their child's oral health. Begzati et al. (2014) found that mothers displayed insufficient knowledge regarding dental visits, feeding, oral hygiene maintenance, and the use of fluoride/antimicrobial agents.

Children whose parents had low parental knowledge of proper oral hygiene had an increased number of dental caries than children whose parents who had more knowledge (Chu et al., 2012; Naidu & Davis, 2008). Elham, Abolghasem, and Tayebeh (2013) evaluated the relationship between parents' oral health behavior and oral health status and behavior of their preschool children, and found a significant relationship between parental frequency of tooth brushing and child frequency of tooth brushing. de Silva-Sanigorski et al. (2013) also reported that higher parental self-efficacy was associated with more frequent tooth brushing (by parent and child) and more frequent visits to a dental professional.

Dental caries are more prevalent in children from families with low-level education and low income. Chu et al. (2012) found that children who came from families with higher income or whose parents had a higher education level had less dental caries. Another study reported a positive association between childhood caries, low parent education, and lower socioeconomic status of the family (Narang, Mittal, Jha, Anamika, & Roseka, 2013). Saldunaite et al. (2014) conducted a study of 1,248 Lithuanian parents of school-aged children. They found that children of parents with high educational levels tended to brush their teeth two times more frequently than those of parents with low educational levels. A greater percentage of children whose parents had a high educational level were more likely to receive preventive dental care and information on personal oral hygiene measures from dental professionals when compared to children from low-income families.

In summary, evidence supports the association between parental knowledge, behavior, self-efficacy, and early childhood caries. Overall findings of the literature review suggest that parents lack knowledge regarding children's oral health, which supports the premise of this research study.

Research Questions

* What is the knowledge level of parents of urban preschool children regarding oral health risk factors?

* What is the relationship between demographic variables and parental knowledge of oral health risk factors for preschool children?

Method

Design and Sample

A descriptive design was used in this study. Power analysis for Pearson correlation was employed to determine the sample size. Using a medium effect size (r = 0.30), alpha of 0.05, power of 0.80, a sample size of 67 was needed (Cohen, 1988). Convenience samples of 100 respondents consisting of parents of children who attend local preschools from the Greater Newark New Jersey community were invited to participate in this study. The authors obtained permission from local childcare centers to interact with the parents of the children. Participants were screened to ensure they met the following inclusion criteria: a) resident of Greater Newark, b) parent of a preschool-age child (two to five years), and c) able to speak and read English or Spanish. After consent was obtained, parents were asked to complete a 17-item questionnaire to assess their knowledge of preschool children's oral health. Responses from 13 questionnaires were not included in the study; four were incomplete and nine did not meet the age inclusion criteria, which resulted in a sample of 87 participants for analysis.

Instrument

The investigators developed the 17-item questionnaire after a careful review of the literature. Questionnaire items were selected based on literature findings regarding causes of children's oral disease and healthy oral health practices. The questionnaire consisted of two sections. The first section collected demographic information, such as child's age, sex, and ethnic background; and parent's age, educational background, income, and their perception of child's dental health and the need for regular dental checkups. The second section included items that assessed parental knowledge of children's oral health risk factors, such as "baby teeth are important," "cavities in baby teeth are permanent," and "eating lots of food or drink that contains sugar may cause cavities." Each item was rated as 1) agree, 2) disagree, or 3) don't know. When scoring the knowledge questions, correct (1) and incorrect (0) format was used. The other alternative (don't know) was scored as an incorrect answer because these responses were perceived as participants not knowing the correct answer. In the correct/incorrect format the total score ranged from 0 to 17, the higher the total score, the greater the knowledge. The questionnaire was reviewed for content validity by two pediatric nurse practitioners with expertise in the content area. Cronbach's alpha was done at the time of the study to determine instrument reliability. The reliability of the instrument was 0.70.

Procedure

Subjects were recruited from daycare centers and preschools from the Greater Newark, New Jersey community after obtaining approval from the Institutional Review Board of Rutgers University and the participating agencies. Subjects were informed of the study when they came to pick up their children at the day care centers and preschools. Those who agreed to participate in the study by signing the consent form completed the questionnaire, which took approximately 10 to 15 minutes. The consent form and the questionnaire were available in English and in Spanish. The Spanish documents were prepared by a professional translation service. The primary investigator or a member of the research team was available to answer any questions. After participants completed the questionnaires, the investigators gave an oral hygiene kit containing an adult and child soft toothbrush and fluoridated toothpaste for children containing the American Dental Association seal of approval to the parent and the child.

Data Analysis

SPSS version 21.0 was used to analyze the data. Demographic information and parental knowledge were analyzed using descriptive statistics. Correlation coefficients were calculated to examine the relationships among variables. Independent t-test was used to see difference in knowledge by ethnicity.

Results

The children's ages ranged from 25 months to 60 months, with the mean age of 44 months (SD=9.33); 57.5% were male and 42.5% were female. Parents' ages ranged from 20 years to 45 years. Two parents reported their age to be above 45 years. The majority of parents (76%) were between the ages of 20 and 40 years. Fifty-seven had Medicaid health insurance (65.5%), 24 had private insurance (27.6%), and six were uninsured (6.9%). Table 1 summarizes demographic data.

Total parental knowledge scores ranged from 7 to 17, with a mean of 11.94 (SD = 2.51), demonstrating a moderate knowledge of children's oral health risks for this group. Correct responses of parents on each knowledge item are presented in Table 2.

Because the majority of participants were African American (36.8%) and Hispanic (51.7%), an independent f-test was used to compare total parental knowledge by these two ethnic groups. Although Hispanic parents had slightly higher oral health knowledge (M = 12.15, SD = 2.41) than African-American parents (M = 11.82, SD = 2.48), there was no significant difference between these two groups in terms of knowledge. There was no correlation between total knowledge and demographic variables except for a negative relationship between total knowledge and age of the parent (r = -0.231, p = 0.05), indicating that the higher the parental age, the lower the total oral health knowledge.

Discussion and Implications

One objective of Healthy People 2020 is to reduce the proportion of children who have dental caries and untreated decay (Office of Disease Prevention and Health Promotion, 2015). AAPD (2014) recommends that parents should be educated about children's oral health to minimize dental problems. Assessment of parental knowledge regarding children's oral health is essential prior to developing an appropriate education program for the target population. Therefore, this study examined parents' reports of childhood oral health risk factors. Findings support the need for healthcare providers, pediatric nurses, and pediatric nurse practitioners to assess parental knowledge of oral health risk and provide education.

Overall, parents who participated in this study were knowledgeable about some aspects of children's oral health risk factors; however, they lacked knowledge in other aspects of oral health care. For example, many parents knew that baby teeth are important (97.7%), and that baby teeth (92%) and permanent teeth (98.9%) need to be brushed twice a day. Yet only a few parents perceived that cavities in baby teeth can cause long-lasting problems (28.7%), and that cavities in baby teeth lead to cavities in permanent teeth (44.8%). In a previous study, researchers reported similar beliefs among family members that baby teeth are not important, and caries in baby teeth are temporary, with no long-term consequences (Isong et al., 2012). Such a belief could result in parents being less attentive to young children's oral health and oral hygiene. Pediatric nurses and pediatric nurse practitioners can help in eliminating such a belief by teaching parents about long-term consequences of caries in primary teeth.

Parents in this study were knowledgeable about the role of food in the development of dental caries; 95.4% reported that eating lots of sugar contained in food or drink may cause cavities. However, few parents believed that cavities may be caused by using a bottle or an infant drinking cup to drink fluids other than water (70.1%) or frequent snacking (60.9%). Regarding the transmission of caries causing bacteria to be spread from parent to child, slightly more than half of the sample reported that germs that cause cavities can be transferred from parents to a child via sharing utensils (56.3%), and approximately three-fourths of the sample thought it is not acceptable for parents to put their child's pacifier or bottle in his or her mouth before giving it to the child (75.9%). A previous study also found that parental knowledge about early infection with S. mutans to be very low (Gussy et al., 2008). Because decreasing bacterial transmission from parent to child is the first step in preventing early childhood caries (Marrs, Trumbley, & Malik, 2011), pediatric nurses and pediatric nurse practitioners must advise parents to avoid saliva-sharing behaviors (e.g., sharing spoons and other utensils, sharing cups, cleaning a dropped pacifier or toy with their mouth).

Fluoride plays a significant role in preventing dental caries (Rozier et al., 2010). A systemic review (Wright et al., 2014) and a meta-analysis of eight clinical trials (Santos, Nadanovsky, & Oliveira, 2013) on caries in preschool children showed that tooth brushing with fluoridated toothpaste significantly reduced dental caries prevalence in the primary dentition. However, in the present study, parents lacked knowledge about the role of fluoride in preventing caries. Only half of the sample perceived the importance of children drinking water that contains fluoride (54%), using fluoride supplements (52.9%), and using fluoride varnish (43.7%). Pediatric nurses and nurse practitioners should educate parents about the importance of fluoride in preventing dental caries and the availability of fluoride in city water or other products, such as bottled water, juice, and vitamins.

It is also essential to warn parents that to prevent fluorosis, fluoride in any form should not be used for children younger than six months of age, and fluoridation supplementation dosage should be based on fluoride levels in local public water sources (Rozier et al., 2010). There are conflicting messages about the use of fluoride and development of mild fluorosis. The decision to use fluoride should be based on the need of an individual child and the risk and benefits (mild fluorosis versus preventing devastating dental caries). To minimize the risk of fluorosis in children while preventing caries, children and parents should be taught that a "smear" or "rice-size" amount of fluoridated tooth-paste should be used for children less than three years of age, and a "pea-size" amount of fluoridated toothpaste for children aged three to six years (Wright et al., 2014).

Seventy-seven percent of parents in this study reported that their child's primary care providers should check for oral cavities, and 95.4% said children should be seen by a dentist even if there are no cavities, which are promising findings. These findings are consistent with one question asked in the demographic information section: "How important to you is the regular dental checkup for your child?" Approximately 89% of parents in this study indicated that regular dental checkups for a child are very important. Parents in this sample seemed to be aware that dental examinations are vital; however, they felt their child's primary care provider should check for caries. Although this level of assessment is usually provided by pediatric and general dentists, findings from this sample were consistent with Isong and colleagues' (2012) findings where parents expected pediatricians to provide education and conduct oral health assessment.

Because of these expectations, along with recommendations from the AAPD and the U.S. Preventive Task Force, it is imperative for primary care providers, including pediatric nurse practitioners, to include oral health assessment and education as a part of routine well-child visits. In one study, pediatricians reported the following barriers in conducting pediatric oral health assessment and educating families regarding oral health care: 1) lack of oral health training (41%), 2) inadequate time during health supervision visits (35%), and 3) inability to bill separately for oral health assessment or counseling (34%) (Lewis et al., 2009). These issues need to be addressed. Nurses are available in a variety of settings and are in a key position to encourage parents to speak with their primary care provider about assessing their children's oral health during well-child visits.

Previous studies reported that some factors, such as parental age, education, educational level, and income, have an impact on a child's oral health (Chu et al., 2012; Narang et al., 2013). In this study, only parental education was negatively correlated to total knowledge, indicating that the higher the parental age, the lower the total oral health knowledge.

Limitation of the Study

This study consisted of a small convenience sample of mostly minority parents in an urban community in New Jersey. Therefore, study findings should be interpreted cautiously. These findings, while useful to illuminate knowledge gaps in this particular group of parents, should not be generalized to all parents of preschool-aged children. Another limitation is the self-reliance on parents' self-reported on oral health knowledge. There is a need for qualitative research to better understand parental knowledge and attitudes related to oral health care.

Conclusion

Preschool children have limited self-care abilities; therefore, parents need to be knowledgeable about oral healthcare so they can supervise, teach, and act as role models for their children. In this study, parents were knowledgeable in certain aspects of children's oral health risk factors but lacked knowledge in others.

The AAPD (2014) emphasizes that effective oral health care requires collaborative efforts between families, early childcare providers and health care professional. Healthcare providers should utilize resources from AAPD (www.aapd.org) and the AAP (www.aap.org) on oral healthcare, policies, evidence-based clinical guidelines, and parent education to update their knowledge and incorporate this information into their practices. Nurse practitioners and nurses can play a key role in promoting oral health and preventing dental caries by providing anticipatory guidance and education to children and their parents at well child visits, during hospitalization, and in school and community settings.

References

American Academy of Pediatric Dentists (AAPD). (2014). Policy on early childhood caries (ECC): Classifications, con sequences, and preventive strategies. Oral Health Policies, 34, 50-52.

Bandura, A. (1986). Foundations of thoughts and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.

Begzati, A., Bytyci, A., Meqa, K., LatifiXhemaili, B., & Berisha, M. (2014). Mothers' behaviors and knowledge related to caries experience of their children. Oral Health and Preventive Dentistry, 12(2), 133-140.

Centers for Disease Control and Prevention (CDC). (2011). Oral health: Preventing cavities, gum disease, tooth loss, and oral cancers at a glance. 2011. Retrieved from https://stacks.cdc.gov/view/cdc/ 11862

Chu, C., Ho, P., & Lo, E. (2012). Oral health status and behaviors of preschool children in Hong Kong. BMC Public Health, 12, 767. Retrieved from http://www. biomedcentral.com/content/pdf/1471 2458-12-767.pdf

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.

de Silva-Sanigorski, A., Ashbolt, R., Green, J., Calache, H., Keith, B., Riggs, E., & Waters, E. (2013). Parental self-efficacy and oral health related knowledge associated with parent and child oral health behaviors and self-reported oral health status. Community Dentistry and Oral Epidemiology, 41, 345-352.

Dye, B.A., Li, X., & Thornton-Evans, G. (2012). Oral health disparities as determined by selected Healthy People 2020 oral health objectives for the United States 20092010. NCHS Data Brief, 104. Retrieved from http://www.cdc.gov/nchs/data/data briefs/db104.pdf

Elham, B., Abolghasem, H., & Tayebeh, M.M. (2013). Oral health behavior of parents as a predictor of oral health status of their children. ISRN Dentistry. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3664493

Gussy, M.G., Waters, E.B., Riggs, E.M., Lo, S.K., & Kilpatrick, N.M. (2008). Parental knowledge, beliefs and behaviors for oral health of toddlers residing in rural Victoria. Australian Dental Journal, 53(1), 52-60.

Isong, I.A., Luff, D., Perrin, J.M., Winickoff, J.P., & Ng, M.W. (2012). Parental perspectives of early childhood caries. Clinical Pediatrics, 5/(1), 77-85.

Lewis, C.W., Boulter, S., Keels, M.A., Krol, D.M., Mouradian, W.E., O'Connor, K.G., & Quinonez, R.B. (2009). Oral health and pediatricians: Results of a national survey. Academy of Pediatric, 9, 457-461.

Marrs, J., Trumbley, S., & Malik,G. (2011). Early childhood caries: Determining the risk factors and assessing the prevention strategies for nursing intervention. Pediatric Nursing, 27(-\), 9-15.

Naidu, R.S., & Davis, L. (2008). Parents'views on factors influencing the dental health of Trinidian preschool children. Community Dentistry and Oral Epidemiology, 34, 102-113.

Narang, R., Mittal, L., Jha, K., Anamika, & Roseka. (2013). Caries experience and its relationship with parent's education, occupation, and socio economic status of the family among 3-6 years old preschool children of Sri Ganganagar city, India. Open Journal of Dentistry and Oral Medicine, 7(1), 1-4. Retrieved from http://www.hrpub.org/download/201309/ ojdom.2013.010101.pdf

National Conference of State Legislatures (2013). Children's oral health. Retrieved from http://www.ncsl.org/research/health/ childrens-oral-health-policy-issuesoverview.aspx

Office of Disease Prevention and Health Promotion. (2015). Oral health. Retrieved from https://www.healthypeople.gov/20 20/topics-objectives/topic/oral-health/ objectives

Prabhu, A., Rao, A.P., Reddy, V., Ahamed, S.S., Mahammad, S., & Thayumanavan, S. (2013). Parental knowledge of preschool child oral health. Journal of Community Health, 38, 880-884.

Rozier, R.G., Adair, S., Graham, F., Lafolla, T., Kingman, A., Kohn, W., ... Meyer, D.M. (2010). Evidenced based recommendation on the prescription of dietary fluoride supplement for caries prevention: A report of the ADA council on scientific affairs. Journal of American Dental Association, 747(12), 1480-1489.

Saldunaite, K., Bendoraitiene, E.A., Slabsinskiene, E., Vasiliauskiene, I., Andruskeviciene, V., & Zubiene, J. (2014). The role of parental education and socioeconomic status in dental caries prevention among Lithuanian children. Medicina, 50(3), 156-161. doi:10. 10164medici.2014.07.003

Santos, A.P.P., Nadanovsky, P., & Oliveira, B.H. (2013). A systematic review and meta-analysis of the effects of fluoride tooth-paste on the prevention of dental caries in the primary dentition of preschool children. Community Dental Oral Epidemiology, 47(1), 1-12.

United States Department of Health and Human Services (DHHS). (2000). Oral health in America: A report of the Surgeon General (NIH Pub. No. 00-4713). Rockville, MD: National Institute of Dental and Craniofacial Research, National Institute of Health.

Wright, J.T., Hanson, N., Ristic, H., Whall, C.W., Estrich, C.G., & Zentz, R.R. (2014). Fluoride toothpaste efficacy and safety in children younger than 6 years. Journal of American Dental Association, 145(2), 182-189.

Ganga Mahat, EdD, RNBC, is a Clinical Professor, School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ.

Felesia Bowen, PhD, DNP, PPCNP-BC, is an Assistant Professor, School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ.
Table 1.
Frequency and Percentages of Demographic Information

                         Frequency   Percentage

Ethnicity
  Caucasian                  4          4.6
  Hispanic                  32          36.8
  African-American          45          51.7
  Asian                      3          3.4
  Other                      3          3.4
Income
  Less than 10,000          20           23
  10,000 to 19,999          13          14.9
  20,000 to 29,999          23          26.4
  30,000 to 39,999          11          12.6
  40,000 to 49,999           4          4.6
  50,000 to 59,999           2          2.3
  60,000 and greater        11          12.6
  No Response                3          3.6
Parental education
  Elementary                 9          10.3
  High school               19          21.8
  High school graduate      19          21.8
  College                   21          24.1
  College graduate          19          21.8
Parents' perception of child's dental health
  Very good                 38          43.7
  Good                      34          39.1
  Fair                      11          12.6
  Poor                       4          4.6
Parents' report of importance of regular dental checkup
  Very important            77          88.5
  Important                  7          8.0
  Somewhat important         1          1.1
  Not important              2          2.3

Table 2.
Frequency and Percentages of Parents' Correct
Responses to Oral Health Knowledge Questions

                                             Frequency   Percentage

Baby teeth are important.                       85          97.7

Baby teeth need to be brushed twice a day.      82          92.0

Permanent teeth need to                         86          98.9
be brushed twice a day.

Cavities in baby teeth are permanent.           25          28.7

Using a bottle or sippy cup to drink            61          70.1
fluids other than water can cause
cavities.

Frequent snacking can cause cavities.           53          60.9

Eating lots of food or drink that               83          95.4
contains sugar may cause cavities.

Children should be seen by the dentist          83          85.4
even if they do not have cavities.

It is important for a child to drink            47          54.0
water that has fluoride in it.

It is important for a child to take             46          52.9
fluoride supplements to prevent cavities.

Fluoride varnish prevents cavities.             38          43.7

Baby teeth need to be flossed.                  48          55.2

Permanent teeth need to be flossed.             78          89.7

Cavities in baby teeth can lead to              39          44.8
cavities in permanent teeth.

My child's primary care provider                67          77.0
should check for cavities.

It is not okay for parents to put their         66          75.9
child's pacifier or bottle in their mouth
before giving it to the child.

Germs that cause cavities can be                49          56.3
transferred from parent to the
child via sharing utensils.
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Author:Mahat, Ganga; Bowen, Felesia
Publication:Pediatric Nursing
Article Type:Report
Geographic Code:1U2NJ
Date:Jan 1, 2017
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