Abstract
Introduction: Parents have an important role ensuring their infants receive oral and medical health care. Their decisions affect the well-being of their children. Methods: This study used data collected from a longitudinal, prospective study with the aim of developing and validating a caries risk assessment tool. The objectives of this study are to (a) compare parents’ perceptions of how well they do in taking care of the infants’ teeth and/or gums versus how well they do in taking care of the infants’ medical health and (b) determine factors associated with parental perceptions of how well they do in taking care of the infants’ teeth and/or gums. Results: A total of 1323 parent/infant pairs were enrolled in the study at Duke University, Indiana University, and the University of Iowa. Through a survey, 283 (21%) of the parents perceived they did an excellent job of both taking care of both the infant’s oral and medical health, while 861 (65%) perceived the care of their infant’s medical health was better than their care of the teeth and/or gums. In the multivariable model, parents who perceived they provided excellent/very good/good care for the infants’ teeth and/or gums were more likely to brush the infant’s teeth daily, use toothpaste daily, clean inside the infant’s mouth and/or gums daily, and not let the infant have something other than water after brushing and prior to bedtime. Also, those with infants having Medicaid or State Insurance, parents not eating sugary snacks frequently, and parents getting dental checkups at least annually were likely to perceive that they provided excellent/very good/good care for their infant’s teeth and/or gums. Conclusions: Parents who provide good infant oral health care are more likely to perceive they provide good care and more likely to have better personal dental health behaviors. This agrees with previous studies concerning older children.
Keywords: parent perception, oral health care, dental health
Parents play an important role ensuring their infants receive oral and medical health care. Their decisions affect the well-being of their children. Oral health is a component of good overall health, as it affects one’s ability to taste, touch, chew, smile, speak, and swallow.1 The Healthy People 2020 national oral health objectives include an important objective to reduce the proportion of children who experience dental caries in their primary teeth.
The American Academy of Pediatric Dentistry recommends that a child’s first dental visit should occur by the end of the first year of life.2 Early childhood caries is a highly prevalent and largely untreated disease in children younger than 3 years.3 From the 2011-2012 National Health and Nutrition Examination Survey, 37% of children aged 2 to 8 years experienced dental caries of their primary teeth and 23% of children aged 2 to 5 years experienced dental caries, nearly half (10%) was untreated.4
Determining factors associated with parents’ perceptions about their infants’ oral health could help primary care medical and dental providers understand some of the reasons why infants do not receive the dental care they need at home or from health care providers and may explain, in part, why children often do not receive treatment until their level of disease requires extensive surgical treatment.5 Understanding these factors is important, as infants cannot verbalize their needs and they are wholly dependent on their parents for ensuring appropriate oral health care. Children who are affected with dental caries at an early age often have the most severe disease occurrences and unfortunately continue to be at considerable risk for future disease.6,7
This study used data collected from a longitudinal, prospective study with the aim of developing and validating a caries risk assessment tool to be used in medical settings to identify young children at highest risk for developing dental caries. The objectives of this article are to (a) compare parents’ perceptions of how well they do in taking care of the infants’ teeth and/or gums versus how well they do in taking care of the infants’ medical health and (b) determine factors associated with parental perceptions of how well they do in taking care of the infants’ teeth and/or gums.
Methods
The principal investigator (M.F.) and the Data and Clinical Coordinating Center (DCCC) are located at the University of Michigan School of Dentistry (Ann Arbor, MI). The DCCC provides a central secure data management system that is responsible for storing all the data from the clinical sites. The three clinical sites are located at Duke University (Duke) (Durham, NC), Indiana University (IU) (Indianapolis, IN), and the University of Iowa (UI) (Iowa City, IA). Institutional review Board approval was obtained at all 4 universities. Each site was charged with oversampling particular subgroups as part of their recruitment process. For example, the recruiters in Iowa expressly sought to identify, recruit, and study pairs of a parent and infant from rural communities, while Indiana emphasized recruiting African American pairs. This resulted in significant differences in race/ethnicity by site as well as differences in age and income by site. Recruitment of participating pairs (primary caregiver and infant) and baseline collection visits were initiated in November 2012 and completed in March 2014.
Pairs were eligible to participate if the infant was 9 to 15 months of age at the time of the baseline visit, the primary caregiver was the legal guardian and could speak English or Spanish and believed that he or she would be able to participate in the study longitudinally, and the infant did not have a history of major systemic disease, including epilepsy or congenital heart disease, and would allow examination of the oral cavity. The definition of a primary caregiver was the individual who resided with the infant and most consistently responsible for the housing, health, and safety of the infant, and who was also the parent or legal guardian. Infants in foster care were excluded. Consented participants included 1238 (94%) mothers, 79 (6%) fathers, 4 (<1%) grandmothers as legal guardians, and 2 (<1%) other legal guardians. In this article, the term parent will be used to refer to all of these: the 99.5% who were parents and 0.5% who were legal guardians.
Parent Questionnaire
The risk assessment tool for the longitudinal parent study was the parent questionnaire used for this study and was a self-administered 52-item questionnaire, with 32 questions concerning the infant, 18 concerning the parent, and 1 each about the parent’s perception of how well the parent takes care of the infant’s teeth and/or gums and medical health. These 2 perception questions read: “I do a _________ job taking care of the child’s teeth and/or gums,” and “I do a _________ job taking care of the child’s medical health.” Answers for these 2 questions were recorded using an ordinal scale, with response options coded 1 through 5 (excellent = 1, very good = 2, good = 3, fair = 4, and poor = 5).
For the 32 questions regarding the infant, 5 asked about the infant’s teeth (ie, any cavities or fillings, use of space maintainers), 7 asked about the infant’s tooth care (ie, frequency of brushing teeth, how often is the toothbrush shared), 6 asked about the infant’s dietary habits (ie, frequency of bottle, frequency of sugary snacks), 4 were related to parent’s behaviors with the infant (ie, sharing food on the same utensil with the infant, kissing the infant on the mouth), 6 focused on professional dental care and health insurance (ie, frequency infant goes to the dentist, dental insurance coverage), 2 were demographic (race, ethnicity), and 2 were about the birth (ie, being born premature by 3 weeks, delivered by C-section).
The 18 questions focusing on the parent included 5 about the parent’s own dental health (ie, How often you brush? Do your gums bleed when brushing?), 3 about their eating habits (ie, frequency of eating sugary snacks, frequency of drinking anything other than plain water before going to bed), 4 concerning the parent’s own medical/dental care and insurance (ie, frequency of dental check-ups, having health insurance), and 6 demographic questions.
Data Analysis
Preliminary descriptive analyses were completed for all key variables to assess the distribution of responses. The Wilcoxon signed-rank test was used to compare the 2 related assessments of the parent’s perception of taking care of the child’s: (a) teeth and/or gums and (b) medical health. Spearman correlations assessed the association between the 2 perception variables. One-way analysis of variance was used to compare continuous variable responses across the 3 sites. The Pearson chi-square test was used to compare discrete variable responses across the 3 sites.
The relationships between parents’ perceptions of taking care of their infants’ teeth and each associated factor were tested using the Cochran-Mantel-Haenszel option in the SAS FREQ procedure, adjusted for the 3 recruitment sites. The dependent variable was based on the question asked of the parent: “I do a ____ job taking care of the child’s teeth and/or gums.” Potential associated factors were categorized into 2 categories depending on the types of responses (yes vs no/don’t know; daily vs weekly/monthly/never; 3 or more times a day/1 or 2 times a day vs weekly/monthly/never; twice yearly/yearly vs only when in pain/every other year/never). Household income was divided into 2 groups (<$40 000/≥$40 000). Because the dependent variable had 5 levels, a homogeneity test across the 3 different sites was conducted using the SAS CATMOD procedure, and we fitted a log-linear model and tested the 3-way interactions among the outcome, the individual associated factors, and the sites using the likelihood ratio test.8
A multivariable prediction model was built to examine the relationships between the outcome variable, the quality of job for the infant’s teeth and/or gums, and the associated factors. The outcome variable was dichotomized into 2 categories, excellent/very good/good versus fair/poor, having an 86%/14% split in responses. The SAS GLIMMIX procedure was used to account for the correlation of subjects within sites. The site effects were specified as the random intercepts in the model. Each of the potential associated factors initially was examined individually. The significant (P < .10) variables from the univariate models were put into the multivariable model. A manual backward selection method was used to remove those nonsignificant variables until all variables were statistically significant (P < .05). Positive coefficients indicate that higher values of the predictor variable are associated with a better outcome. All analyses were performed using SAS version 9.3 (SAS Institute Inc, Cary, NC).
Results
A total of 1326 participants were enrolled in the study; 3 did not complete the first visit, leaving 1,323 participants: 432 from Duke, 543 from IU, and 348 from UI. The majority of the parents were female (94%), with a mean age of 28.7 years (see Table 1). Half of the infants were male (51%), with a mean age of 11.4 months. Half of the parents self-identified as white (49%), 40% Black/African American, and 11% Hispanic. Race and ethnicity provided by the parent for infants were similar to those of the parents. Forty-nine percent of the parents reported an annual household income of less than $40 000. No significant differences were found in either the parental perceptions of their job taking care of the infant’s teeth and/or gums or of their job taking care of the infant’s medical health, when comparing subjects across the 3 sites, when adjusted for the demographic (gender, age, race, and ethnicity) and household income responses.
Table 1.
Demographic and Socioeconomic Status of Parents and Infants.
| All Participants, n (%) | |
|---|---|
| Parent n = 1323 | |
| Gender | |
| Male | 79 (6.0) |
| Female | 1244 (94.0) |
| Age, years, mean ± SD | 28.7 ± 6.0 |
| Race | |
| Black/African American | 527 (39.8) |
| Native American | 7 (0.5) |
| Asian | 30 (2.3) |
| White | 646 (48.8) |
| More than one race | 65 (4.9) |
| Other | 48 (3.6) |
| Ethnicity | |
| Hispanic | 145 (11.0) |
| Annual household income, $ | |
| <10 000 | 308 (23.3) |
| 10 000 to <40 000 | 344 (26.1) |
| 40 000 to <80 000 | 250 (18.9) |
| ≥$80 000 | 257 (19.4) |
| Don’t know | 162 (12.3) |
| Infant n = 1323 | |
| Gender | |
| Male | 674 (50.9) |
| Female | 649 (49.1) |
| Age, months, mean ± SD | 11.4 ± 2.0 |
| Race | |
| Black/African American | 510 (38.6) |
| Native American | 4 (0.3) |
| Asian | 21 (1.6) |
| White | 581 (43.9) |
| More than one race | 165 (12.5) |
| Other | 42 (3.2) |
| Ethnicity | |
| Hispanic | 177 (13.4) |
Of the 1323 parents, 283 (21.4%) perceived they did an excellent job of both taking care of both the infant’s oral and medical health. Of the 1323 parents, 896 (67.7%) perceived they did an excellent job of taking care of the infant’s medical health, 350 (26.5%) a very good job, 71 (5.4%) a good job, 6 (0.4%) a fair job, and no one reported they did a poor job (see Table 2). In contrast, 292 (22.1%) perceived they did an excellent job of taking care of the infant’s teeth and/or gums, 402 (30.4%) a very good job, and 443 (33.5%) a good job, 149 (11.2%) a fair job, and37 (2.8%) a poor job. Thirty-four percent reported the same level of perception of care for medical and oral health. The percent agreement per the 5 answer choices for both perception questions was highest at 21.4% for the excellent category followed by very good at 8.6%, good at 3.6%, and fair at 0.4% (see Table 2). Sixty-five percent of the parents perceived the care of their infant’s medical health was better than their care of the teeth and/or gums compared to only 0.9% of parents who thought their care of oral health was better.
Table 2.
Parental Perceptions of Their Job Taking Care of Their Infants’ Teeth/Gums and Medical Health.
| Parental Perceptions of Their Job Taking Care of Their Infants’ Medical Health |
|||||||
|---|---|---|---|---|---|---|---|
| Excellent | Very Good | Good | Fair | Poor | Total | ||
| Parental Perceptions of Their Job Taking Care of Their Infants’ Teeth/Gums | Excellent | 283 (21.4) | 8 (0.6) | 1 (0.1) | 0 | 0 | 292 (22.1) |
| Very Good | 286 (21.6) | 114 (8.6) | 2 (0.2) | 0 | 0 | 402 (30.4) | |
| Good | 217 (16.4) | 177 (13.4) | 48 (3.6) | 1 (0.1) | 0 | 443 (33.5) | |
| Fair | 87 (6.6) | 43 (3.3) | 14 (1.1) | 5 (0.4) | 0 | 149 (11.2) | |
| Poor | 23 (2.6) | 8 (0.6) | 6 (0.5) | 0 | 0 | 37 (2.8) | |
| Total | 896 (67.7) | 350 (26.5) | 71 (5.4) | 6 (0.4) | 0 | 1,323 | |
The median for parents’ perception of their job taking care of the infant’s medical health was 1.0 (interquartile range, 1.0-2.0), and the median for parent’s perception of their job taking care of the infant’s teeth and/or gums was 2.0 (interquartile range, 2.0-3.0) on the scale of 1 to 5; the distribution of these 2 scales was skewed. Although the 2 perception variables correlated significantly at r(s) = 0.35 (P < .0001), there was a statistically significant difference with parents’ perceptions of care for their infants’ medical health better than their perceptions of care for the infants’ teeth and/or gums (P < .0001).
Many factors, such as daily brushing of the infant’s teeth and use of toothpaste, including demographic characteristics and provision of oral health care, were associated with the parents’ perceptions of their job taking care of the infants’ teeth and/or gums (see Table 3). Parents who reported eating sugary snacks between meals less often than daily were more likely to perceive that they did an excellent, very good, or good job of caring for the infant’s teeth and/or gums. Similarly, parents who visited their health care provider and got dental check-ups annually or twice annually were more likely to perceive they did an excellent, very good, or good job (see Table 3). Testing homogeneity across sites indicated no significant differences in perceptions of taking care of their infant’s teeth and/or gums by infant study risk factors across the 3 different sites.
Table 3.
Factors Associated With Parental Perceptions of How Well They Provided Infant Oral Health Care (n = 1323).a
| Parent’s Perception of Taking Care of Their Infant’s Teeth/Gums, n (%) |
|||||
|---|---|---|---|---|---|
| Excellent; n = 292 (22.1) | Very Good; n = 402 (30.4) | Good; n = 443 (33.5) | Fair; n = 149 (11.3) | Poor; n = 37 (2.8) | |
| 1. How often does an adult brush your child’s teeth?b | |||||
| Daily, n = 705 (53.2%) | 183 (62.7) | 280 (69.7) | 213 (48.1) | 29 (19.5) | 0 |
| Weekly/monthly/never, n = 618 (46.7%) | 109 (37.3) | 122 (30.3) | 230 (51.9) | 120 (80.5) | 37 (100) |
| 2. How often are your child’s teeth brushed with any toothpaste?b | |||||
| Daily, n = 402 (30.4%) | 112 (38.4) | 172 (42.8) | 108 (24.4) | 10 (6.7) | 0 |
| Weekly/monthly/never, n = 921 (69.6%) | 180 (61.6) | 230 (57.2) | 335 (75.6) | 139 (93.3) | 37 (100) |
| 3. How often are your child’s teeth brushed with non-fluoride toothpaste?b | |||||
| Daily, n = 286 (21.6%) | 88 (30.1) | 119 (29.6) | 71 (16.0) | 8 (5.4) | 0 |
| Weekly/monthly/never, n = 1037 (78.4%) | 204 (69.9) | 283 (70.4) | 372 (84.0) | 141 (94.6) | 37 (100) |
| 4. How often do you check your child’s teeth for anything unusual?b | |||||
| Daily, n = 529 (40.0%) | 165 (56.5) | 173 (43.0) | 133 (30.0) | 49 (32.9) | 9 (24.3) |
| Weekly/monthly/never, n = 794 (60.0%) | 127 (43.5) | 229 (57.0) | 310 (70.0) | 100 (67.1) | 28 (75.7) |
| 5. How often do you clean (with or without a toothbrush) inside your child’s mouth and/or gums?b | |||||
| Daily, n = 750 (56.7%) | 211 (72.3) | 281 (69.9) | 216 (48.8) | 37 (24.8) | 5 (13.5) |
| Weekly/monthly/never, n = 573 (43.3%) | 81 (27.7) | 121 (30.1) | 227 (51.2) | 112 (75.2) | 32 (86.5) |
| 6. How often does your child eat or drink anything other than plain water before going to bed (and after you have brushed his/her teeth, if teeth are brushed)?c | |||||
| Daily, n = 834 (63.0%) | 184 (63.0) | 231 (57.5) | 277 (62.5) | 113 (75.8) | 29 (78.4) |
| Weekly/monthly/never, n = 489 (37.0%) | 108 (37.0) | 171 (42.5) | 166 (37.5) | 36 (24.2) | 8 (21.6) |
| 7. How often do you take your child to the dentist?b | |||||
| Never/only when in pain, n =1136 (85.9%) | 245 (83.9) | 332 (82.6) | 387 (87.4) | 139 (93.3) | 33 (89.2) |
| Yearly/twice yearly, n = 187 (14.1%) | 47 (16.1) | 70 (17.4) | 56 (12.6) | 10 (6.7) | 4 (10.8) |
| 8. Is your child’s care covered by Medicaid or State Insurance?b | |||||
| Yes, n = 810 (61.2%) | 225 (77.1) | 243 (60.5) | 245 (55.3) | 78 (52.4) | 19 (51.4) |
| No/don’t know, n = 513 (38.8%) | 67 (22.9) | 159 (39.5) | 198 (44.7) | 71 (47.6) | 18 (48.6) |
| 9. Is your child covered by any health insurance other than/or in addition to Medicaid or State Insurance?d | |||||
| Yes, n = 594 (44.9%) | 96 (32.9) | 187 (46.5) | 220 (49.7) | 73 (49.0) | 18 (48.7) |
| No/don’t know n = 729 (55.1%) | 196 (67.1) | 215 (53.5) | 223 (50.3) | 76 (51.0) | 19 (51.3) |
| 10. Does your child participate in public assistance programs?b | |||||
| Yes, n = 788 (59.6%) | 220 (75.3) | 233 (58.0) | 236 (53.3) | 80 (53.7) | 19 (51.4) |
| No/don’t know, n = 535 (40.4%) | 72 (24.7) | 169 (42.0) | 207 (46.7) | 69 (46.3) | 18 (48.6) |
| 11. How often do you eat sugary snacks such as raisins, candy, cookies, cakes, or cereal bars between meals?d | |||||
| 1 or 2 times/day or >3 times/day, n = 787 (59.5%) | 171 (58.6) | 233 (58.0) | 258 (58.2) | 96 (64.4) | 29 (78.4) |
| Weekly/monthly/never, n = 536 (40.5%) | 121 (41.4) | 169 (42.0) | 185 (41.8) | 53 (35.6) | 8 (21.6) |
| 12. How often do you see your health care provider for regular check-ups?d | |||||
| Yearly/twice yearly, n = 1119 (84.6%) | 256 (87.7) | 353 (87.8) | 368 (83.1) | 115 (77.2) | 27 (73.0) |
| Every other year/never, n = 204 (15.4%) | 36 (12.3) | 49 (12.2) | 75 (16.9) | 34 (22.8) | 10 (27.0) |
| 13. How often do you get dental check-ups?† | |||||
| Yearly/Twice yearly n = 938 (70.9%) | 223 (76.4) | 292 (72.6) | 312 (70.4) | 89 (59.7) | 22 (59.5) |
| Every other year/Never n = 385 (29.1%) | 69 (23.6) | 110 (27.4) | 131 (29.6) | 60 (40.3) | 15 (40.5) |
| 14. Do you consider your child to be Spanish, Hispanic, or Latino?d | |||||
| Yes, n = 177 (13.4%) | 30 (10.3) | 48 (12.0) | 69 (15.7) | 19 (12.8) | 11 (29.7) |
| No, n = 1140 (86.6%) | 262 (89.7) | 352 (88.0) | 370 (84.3) | 130 (87.2) | 26 (70.3) |
| 15. What is your racial background?b | |||||
| Black/African American, n = 527 (39.8%) | 179 (61.3) | 162 (40.3) | 132 (29.8) | 46 (30.9) | 8 (21.6) |
| White, n = 646 (48.8%) | 81 (27.7) | 200 (49.8) | 259 (58.5) | 84 (56.4) | 22 (59.5) |
| Other, n = 48 (3.6%) | 32 (11.0) | 40 (10.0) | 52 (11.7) | 19 (12.8) | 7 (18.9) |
| 16. Is an adult in the child’s household employed?b | |||||
| Yes, n = 1,085 (82.0%) | 208 (71.2) | 336 (83.6) | 382 (86.2) | 126 (84.6) | 33 (89.2) |
| No, n = 238 (18.0%) | 84 (28.8) | 66 (16.4) | 61 (13.8) | 23 (15.4) | 4 (10.8) |
| 17. Which of the following categories best represents the combined income of all family members in your household for the past 12 months?b | |||||
| <$40 000, n = 652 (56.3%) | 190 (76.6) | 190 (53.4) | 197 (50.5) | 60 (45.8) | 15 (44.1) |
| ≥$40 000, n = 507 (43.7%) | 58 (23.4) | 166 (46.6) | 193 (49.5) | 71 (54.2) | 19 (55.9) |
Cochran-Mantel-Haenszel chi-square test adjusted for 3 sites.
P < .0001.
P < .001.
P < .05.
The multivariable PROC GLIMMIX model shows parents who perceived they provided excellent/very good/good care for the infants’ teeth and/or gums were more likely to brush the infant’s teeth daily, use toothpaste daily, clean inside the infant’s mouth and/or gums daily, and not let the infant have something other than water after brushing and prior to bedtime (see Table 4). Also, those with infants having Medicaid or State Insurance, parents not eating sugary snacks frequently, and parents getting dental checkups at least annually were likely to perceive that they provided excellent/very good/good care for their infant’s teeth and/or gums. Ten other factors significant in the bivariate analyses were not confirmed in the multivariable analysis.
Table 4.
Multiple Logistic Model of Factors Associated With Parental Perceptions of doing an Excellent/Very Good/Gooda Job of Taking Care of Their Infant’s Teeth/Gums (n = 1323).
| Effect | Odds Ratio (95% CI) | P |
|---|---|---|
| Brushes infant’s teeth daily | 2.93 (1.68-5.11) | <.001 |
| Brushes infant’s teeth with tooth paste daily | 2.62 (1.19-5.75) | .02 |
| Cleans inside infant’s mouth and/or gums daily | 2.35 (1.53-3.62) | <.001 |
| Allows infant to eat or drink after brushing their teeth and before going to bed daily | 0.59 (0.40-0.87) | .01 |
| Infant is covered by Medicaid or State Insurance | 1.75 (1.21-2.54) | .01 |
| Parent eats sugary snacks after brushing their teeth and prior to going to bed daily | 0.64 (0.45-0.92) | .02 |
| Parent gets dental check-ups yearly or twice yearly | 1.74 (1.24-2.56) | .01 |
Dichotomized as excellent/very good/good (86%) versus fair/poor (14%).
Discussion
Many parents perceived that they take better care of their infant’s medical health than they do of their infant’s teeth and/or gums. Each system of the body affects other systems; it is important that parents are educated to recognize that all the body’s systems are inter-related. As noted by the World Health Organization, oral health affects one’s general health and can change what people eat, how they talk, and their quality of life.9
In this study, most parents rated provision of their infant’s medical health better than their provisions for their teeth and/or gums. In another study that surveyed 707 parents of 8-year-old children, parents rated their children’s overall health to be superior to their oral health.10 In the 2011-2012 US National Survey of Children’s Health,11 84% of the parents rated their child’s health (0-17 years of age) as excellent/very good, while 84% of parents also rated their 10- to 18-month-old’s overall health as excellent/very good in the National Survey of Early Childhood Health.12 This compares with 94% of parents in the present study rating their perception of taking care of their child’s medical health as excellent/very good, but only 43% rating their perception of taking care of their child’s teeth and/or gums as excellent/very good.
In our study, the parent’s actual provision of good oral care for their infants correlated with the perception good oral health care. Those who reported not brushing their infant’s teeth on at least a daily basis, using toothpaste, cleaning the oral cavity, or allowing ingestion of milk or sugared beverages at bedtime were more likely to perceive their job of taking care of the teeth and/or gums as poor.
Interestingly, the use of dental services by the parent has close ties to the parental perception of the infant’s oral health and or medical care.13,14 Our data indicates that a parent having at least annual dental professional care was associated with having a more positive perception of their ability to maintain their infant’s oral health. This is of importance as data from other investigations indicate that the frequent use of professional dental services by the caregiver was a predictor of the infant receiving such services.13-15 For those parents who do not receive regular dental care, the infant should be considered at risk.13
At present, there is little published data regarding parental perceptions of the oral health of children as young as those in our current study. A study of 478 parents who were asked to categorize their child’s oral health as better or worse than that of other children of similar age found that parents who perceived their child’s oral health was worse or equal to the other children’s oral health reported a lower frequency of tooth brushing when compared with those who possessed a more positive perception.16
Other studies focusing on parents’ perceptions of oral health have focused on children receiving special education in school5,10 and minority groups.17 A higher percentage of parents of children with special health care needs reported that their children had fair to poor dental health, even though they had dental coverage for preventive care, compared with parental reports of children without special health care needs.5 The same findings were reported by Butani and colleagues10 as Kenney and colleagues.5 In a study of 885 low-income African American caregivers, 21% rated their children’s oral health as fair to poor. For those children whose caregivers rated their oral health as poor, there was a significant association with caries for that child.17
For health care providers, emphasizing good oral health behaviors and teaching the basics is important, especially for those patients (parents) who do not demonstrate those good behaviors. It is important to ask the questions, “Do you brush your infant’s teeth daily?” and “Do you brush your infant’s teeth with toothpaste?” Unfortunately, the costs of dental visits and oral hygiene products can be factors in one’s undertaking to practice good oral health behaviors. In the past, few medical plans included coverage for dental expenses, which were mainly covered through separate policies; further, dental insurance coverage was much less prevalent than medical insurance in the United States.18 The Affordable Care Act has offered health insurance to millions of Americans and provided more choices for dental benefits, but the cost for dental insurance could still be prohibitive for many families.19
Limitations of this study are that no educational level question was asked of the parents and that the entire study relies on self-reported data. Strengths of this study are that it was conducted at three different sites and had external monitoring of data management and entry. This study provides new information regarding parents’ own oral health care and their infants’ oral health care in relation to their perceptions of how well they provide oral and medical health care for their children.
Conclusions
Good health is attained largely through one’s health habits; good oral health is achievable through specific health habits that are practiced conscientiously, that is, brushing teeth with fluoridated toothpaste, routinely having dental examinations, and avoiding eating after brushing teeth and prior to sleep. Parents are important roles models that a child can have for learning good oral health habits. Those parents in this study who indicated poor oral health habits for themselves and their infants, also perceived their job of taking care of the infants’ teeth and/or gums was fair/poor.
Two-thirds of the parents perceived that they provided better care of their infants’ medical health than their infants’ oral health. Reasons for this warrant further study. Determining if perceptions should be similar warrants further study. The findings in this study suggest that parents who provide good infant oral health care are more likely to perceive they provide good care, and this agrees with previous studies reporting that parents’ perceptions are a good indicator of their children’s oral health.17
Author Biographies
Jeanette M. Daly, RN, PhD, is an associate research scientist in the Department of Family Medicine in the Roy J. and Lucille A. Carver College of Medicine. She is the associate director of the Iowa Research Network, a practice-based research network.
Steven M. Levy, DDS, MPH, is Wright-Bush-Shreves professor of Research and Graduate Program associate director, Dental Public Health, in the Department of Preventive and Community Dentistry, College of Dentistry, and also professor in the Department of Epidemiology, College of Public Health, University of Iowa. He is an oral epidemiologist actively involved with research about dental caries, dental fluorosis, uses of fluorides, and other aspects of prevention. He is principal investigator or investigator on several NIH and other grant awards.
Yinghui Xu, MS, is a biostatistician in the Department of Family Medicine at the University of Iowa. She performs statistical analyses, develops and maintains databases for research studies.
Richard D. Jackson, DMD, is an associate professor in the Department of Cariology, Operative Dentistry and Dental Public Health at the Indiana University School of Dentistry. His primary research interest is focused in the area of caries risk assessment in adults, children and special populations. He also has an interest in the importance of oral health as a key component of inter-professional education.
George J. Eckert, MAS, is the biostatistician supervisor in the Department of Biostatistics at the Indiana University School of Medicine and the program manager of the Design and Biostatistics Program of the Indiana CTSI. He has collaborated extensively with researchers in the area of caries risk assessment and other areas of dental research.
Barcey T. Levy, PhD, MD, is a professor of Family Medicine in the Roy J. and Lucille A. Carver College of Medicine and Epidemiology in the College of Public Health at the University of Iowa. She is the director of the Iowa Research Network, a practice-based family medicine research network. Her main research interests are improving colorectal cancer screening, test characteristics of fecal immunochemical tests, and prevention.
Margherita Fontana, DDS, PhD, holds the position of professor in the Department of Cariology, Restorative Sciences and Endodontics at the University of Michigan School of Dentistry, where she also serves as cariology discipline co-coordinator. As a principal investigator, she has received research grants from the National Institute of Health, the American Association of Pediatric Dentistry, Centers for Medicare and Medicaid, the Delta Dental Fund, DentaQuest, and private industry. In 2012 she received the Presidential Early Career Award for Scientists and Engineers (PECASE) for her work on caries risk assessment in children.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by National Institutes of Health (NIH) U01 DE021412-01A1 and NIH CTSA grants: UL1-TR000442 (University of Iowa), 2UL1TR000433 (University of Michigan), and TR000006 (Indiana University).
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