Family related factors associated with caries

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Original Article

Family related factors associated with caries prevalence in the primary dentition of five-year-old children Amrita Sujlana, Parampreet Kaur Pannu1 Senior Lecturer, Department of Pediatric and Preventive Dentistry, 1Professor and Head, Bhagat Singh, Rajguru and Sukhdev Dental College and Hospital (BRS), Barwala, Panchkula, Haryana, India

ABSTRACT Background: Habits formed in childhood dictate lifestyle choices made as adults. These encompass both oral hygiene and dietary habits which in turn affect dental caries status. Children largely acquire these habits from modeling/observing parents and other family members. Aim: The purpose of this study was to assess the caries status of 5-year-olds, and evaluate associations between dental caries and family-related factors. Materials and Methods: A cohort of 400 children were examined for dental caries using the WHO criteria. Parents were interviewed using a self-structured questionnaire to collect data with regard to variables under evaluation. Statistical analysis: Collected data was subjected to descriptive analysis using the SPSS 12.0 version. Risk factor association with dental caries was investigated using a stepwise logistic regression analysis with P-values < 0.05 considered significant. Results: Fifty nine percent of children suffered from dental caries. Statistically significant risk indicators for a child having dmft > 0 were: Mother with low basic education (OR = 1.3), higher number of siblings (OR = 1.4), high snacking frequency (OR = 2.0), parental inability to control sugar consumption (OR = 1.0) parental laxness about the child’s tooth brushing (OR = 1.5), parents brushing their own teeth less than twice daily (OR= 2.0) and unassisted brushing by the child (OR = 1.8). Conclusion: It is thus mandatory to focus on parents’ education level, attitudes and family-structure when planning preventive programs for young children.

KEYWORDS: Dental caries, family, prevalence

Introduction Habits children acquire early in life continue to shape attitude and lifestyle choices they make as adults. Thus, good oral hygiene and dietary habits adopted at an early age ensure optimal oral health later in life.

Address for correspondence: Dr. Amrita Sujlana, House no. 149, Silver City Main, Zirakpur - 140 603, Punjab, India. E-mail: [email protected] Access this article online Quick response code

Website: www.jisppd.com DOI: 10.4103/0970-4388.155108 PMID: ******

In accordance with the Social Learning theory these habits are largely acquired through observational learning and modeling. For a child, significant others are primarily, the parents and immediate family members.[1] Parents inculcate good habits in their children based on their own attitudes and beliefs. Various intergeneration processes connect parental oral health status with that of their offspring.[2,3] At the age of 5 years, a child’s dietary choices and oral hygiene behavior, and consequently their dental health is predominantly dictated by their care givers. The choices parents make are influenced by a variety of factors which include their oral health attitudes, behaviors as well as various socio-demographic factors. Thus all these factors may collectively have the potential to affect oral health outcomes. Previously conducted studies have establishes that family related factors definitely impact dental caries experience in the primary dentition. A study conducted by Matilla et al., concluded that focusing on parents to improve oral health outcomes of their children is an indispensible sine qua non.[1] Furthermore studies have proposed that the family structure possibly influence dental caries in children.[4,5] Thus the present study was conducted to examine the prevalence of dental caries in 5-year old children

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2015 | Vol 33 | Issue 2 |

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Sujlana and Pannu: Correlating prevalence of dental caries in the primary dentition with family-related risk factors

and focus on the influence of family-related and socio-demographic factors on the child’s caries experience and oral health behavior.

Materials and Methods The present cross-sectional study was conducted in the Pinjore Block (Panchkula), Haryana, India. A power analysis was carried out to select a representative sample of 5-year-old children (n = 400) from government schools and their parents.

Sample selection

Every third school was selected randomly using a list obtained from the local governing body. After taking necessary permission from the school administration to carry out the survey, we proceeded to select the children to be enrolled. All children aged 5 years (+6 months) were eligible for the study. A roll of all students falling in to the age bracket was prepared and every third child was selected. Parents of the selected children were invited to the school premises for an interview. All respondents were selected following which their children were examined for dental caries. All invited parents participated in the study.

Questionnaire

Data concerning the independent variables were collected using a self-structured questionnaire and were divided into four broad categories [Table 1]. • Socio-demographic variables were assessed by questioning parents about their occupation, educational level and monthly income. These together were used to evaluate the parents socioeconomic status using the a revised version of the Kuppuswamy’s Socioeconomic Status (SES) Scale.[6] Only economic criteria in the scale were modified by using a conversion factor of 13.57 calculated after considering the All India Average Consumer Price index for Industrial Workers (CPI-IW) as published by Labor Bureau, Government of India, Delhi. • Family structure was assessed by questioning whether the family was nuclear or joint, how many siblings the child had and the child order in family. • Attitudinal variables concerning sugar consumption, tooth-brushing and dental caries were assessed. With regard to sugar consumption, the parents were asked about the frequency of sugar snacking (both snacks as well as beverages) by the child and ability of the parent to control their child’s sugar consumption. The child’s toothbrushing frequency and parents inclination to ensure twice daily brushing was questioned, along with whether brushing was assisted or not. To assess attitude towards dental decay, parents were asked if they considered it important to protect milk teeth against dental caries and also whether they presumed that dental decay to be an inevitable 84

•

process. Cronbach’s α of 0.72 was calculated with regard to this aspect of the questionnaire displaying good internal consistency. Parents’ oral hygiene and dental-care seeking behavior was also evaluated. Brushing frequency was determined and the parent was questioned whether they went for regular dental checkups.

Oral examination for the children was carried out in a natural setting, with the child seated in an ordinary chair facing away from direct sunlight. A mouth mirror and blunt probe were used to examine the caries status using the WHO criteria for dental caries assessment.

Statistical analysis

Mean dmft, dt, mt and ft was calculated via descriptive statistical analysis using the SPSS 12 version. A bivariate analysis was carried out to check for association between each independent variable and the dental caries status of the child. Variables showing a significant association were then subjected to a logistic regression analysis. Odds ratio (OR) and 95% confidence interval (95% CI) were calculated, with P-values < 0.05 considered significant.

Results Dental health status

Absence of dental caries (dmft = 0) was found in 164 (41%) of 400 children. The number of children with dmft >1 were 236 (59%). A high dmft score (dmft >4) was present in 88 (22%) children. The mean dmft index was 2.79 (+ 3.16). The decayed component (dt) contributed most to the total dmft 2.72 (+ 3.14) and a small proportion came from the filled component (ft) 0.07 (+ 0.52).

Socio-demographic factor analysis

On evaluating the SES variables using Kuppuswamy’s SES Scale, we found that 98% of the children were from the lower middle class strata of society. A stepwise logistic regression found only the mothers’ level of education to be significantly associated the dental caries status of children. A higher level of mothers’ basic education was significantly related to dmft = 0 (P < 0.001) [Table 2]. No significant association was seen with the fathers’ level of education or occupation of the parents. Since the family income was comparable in the cohort at large, comparison with the dmft gave no significant result.

Family-related factor analysis

Of all the children enrolled 286 had siblings. A higher number of siblings was found to be significantly associated with higher caries status (P = 0.04). However, the child order in the family or family structure did not significantly affect the dmft score.

Parental-Attitude factor analysis

When considering attitude of the parents with respect to sugar consumption, we found that a higher




Table 1: Frequency of the variables assessed Variable Frequencies % Mother Education level Low 248 62 High 152 38 Father Education level Low 141 35.3 High 259 64.7 Child order in Family First child 114 28.5 Second/Third Child 286 71.5 No. of Siblings 0-1 262 65.5 2 138 34.5 Type of family Nuclear 264 66 Joint 136 34 How many times is the child allowed to snack on sweets/sweetened beverages per day? 0-2 78 19.5 >3 322 80.5 Are you able to control your child’s sugar consumption? Yes 16 4 No 384 96 Do you ensure that your child brushes twice daily? Yes 136 34 No 264 66 Do you assist the child while brushing? Yes 260 65 No 140 35 Do you think it is important to protect milk teeth against decay? Yes 162 40.5 No 238 59.5 Do you believe that decay an inevitable process? Yes 392 98 No 8 2 Do you brush twice daily? Yes 162 40.5 No 238 59.5 Do you go for regular dental visits? Yes 8 2 No 392 98 What kind of a dentifrice do you use? Fluoridated 372 93 Non-fluoridated 28 7

snacking frequency almost doubles the odds of a child suffering from dental caries (P = 0.001). Additionally, a significantly positive association was found between parents inefficacy to control snacking with dmft score >0 (P < 0.0001). Parents who insisted on their children brushing twice daily had children with lower dmft scores. A higher brushing frequency was significantly related

Table 2: Multiple logistic regression of independent variables associated with dental caries Variable

Mother Education level Low* High No. of Siblings 0-1 >2* Snacking frequency High > 3* Low 0-2 Ability to control child’s sugar consumption Yes No* Brushing frequency of child Once daily* Twice and more Do you assist the child when brushing? Yes No* Do you brush twice daily? Yes No*

P value

Adjusted 95% Odds Confidence Ratio (OR) Interval (CI)

0.001

1.3

1.1-1.5

0.046

1.4

1.0-1.9

0.001

2.0

1.5-2.4

0.

Parental-behavior factor analysis

Parents who brushed their own teeth twice daily had higher chances of having children with dmft = 0 (P < 0.001). No significant differences between children with dmft > 0 and those with dmft = 0 was seen with regard to the parents’ dentalcare seeking behavior. A high percentage of parents (97.99%) thought it irrelevant to go for regular dental visits.

Discussion The primary purpose of our study was to evaluate the prevalence of dental caries in 5-year-old children. We found more than half of the children suffering from dental caries in the representative study sample. Most of the contribution towards the dmft came from the decayed component, displaying urgent need for both reparative as well as preventive care in the population under consideration.


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Furthermore, we aimed to identify family-related risk factors for dental caries experience in the primary dentition. According to some studies, parental employment status, dental attitudes and dental behavior strongly influence the caries status of their 5-year-old children.[7,8] The main factors associated with a child’s dmft > 0 in 5-year-olds were: Mothers’ lower level of basic education, higher number of siblings, higher snacking frequency permitted by parents, inability of parents to control sugar consumption, parents lax attitude when regulating brushing frequency, unassisted brushing by the children and parents’ not brushing their own teeth twice daily. Parents’ education level has been associated with the level of caries experience in their children time and again.[9-12] In our study, only the mothers’ level of education was found to be associated with the dental caries experience in their children, while no such association was seen with the fathers’ level of education. Two other studies have also observes that the mothers’ level of education, and not the fathers’, influence oral health related quality of life.[13,14] These results may have resulted from the differences in parental roles in these countries, fathers being primarily the breadwinners, and mothers being involved in child-rearing.

established fact.[20,21] As stated in the policy guidelines on early childhood caries (American Academy of Pediatric Dentistry) a parent must assist the child when brushing is performed.[22] This is because children younger than 10 years of age lack the motivation as well as the manual dexterity to perform effective tooth brushing.[23] Studies have shown that younger children have difficulty performing certain movements when brushing and hand function is age related.[24] In addition, our study also found that parents not brushing twice daily themselves increase the odds of their children suffering from dental caries. Although no significant association was seen between the parents’ dental attendance and dmft score of their children, we found that almost 98% of the parents did not go for regular dental visits. Their concept of being healthy is absence of disease, and they focus primarily on disease management rather than disease prevention. Along with this nonchalant attitude, other factors which have been identified to affect the dental attendance pattern include the socioeconomic status and dental anxiety.[25] The patrons in our study were from the lower middle or the lower class of society which could have resulted in the low percentage of dental attendance.

Family as a cultural unit influences the attitudes and beliefs of its members. With fast emerging nuclear families, the question arises whether a child receives adequate care and attention. In our study, family-structure (that is nulear or joint family) did not influence the child’s caries experience. This finding may be explained on the basis that independent of the family-structure, it is the parents who invest time and effort in their children. Of all the variables assessed only the number of siblings was a crucial factor in assessing the caries risk. There have been previous reports linking higher number of siblings to increased dental caries experience in young children.[15] Larger families units are a proxy indicator of the SES and in turn affects oral health as well as general health.[16]

Any study evaluating such factors must consider that both memory bias as well as socially accepted answers has an effect on the final result. Although an effort was made to ensure internal consistency of the questionnaire, these former factors cannot be controlled.

Parental leniency and inefficiency when regulating sugar consumption were highly significant factors affecting the caries status in their children. Reducing a child’s sugar snacking is essential not only for good oral health, but also preventing chronic problems such as diabetes, obesity, cardiovascular diseases, etc.[17-19] It is important that parents understand their significance when it comes to implementing such behaviors in their children.

Conclusion

Children are more likely to be free from caries if they brush twice daily and their brushing is supervised. Supporting this statement, our study established that a parents’ inability to systemize or assist in their child’s tooth brushing efforts was associated with presence of dental caries in the children. Regular tooth brushing having an impact on dental caries status is an

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Without doubt, motivation and education of parents against unhealthy dietary and oral hygiene choices is key when trying to achieve good oral health for children. In addition, another area which needs exploration is the influence of a parents’ sense of coherence on the oral health of their child, as education and motivation alone may fall short to achieve our goal. Further studies with longitudinal design are needed to corroborate our findings.

The foundation of lifestyle choices in adulthood is laid down during the formative years of a child’s life. Children are dependent on their environment (that is the family) to institute favorable oral health behaviors’. Thus, assessing family-related risk factors is essential when instituting preventive/treatment programs for young children.

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How to cite this article: Pannu PK, Sujlana A. Family related factors associated with caries prevalence in the primary dentition of five-year-old children. J Indian Soc Pedod Prev Dent 2015;33:83-7. Source of Support: Nil, Conflict of Interest: None declared.


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