Table 6.

PROMIS Parent Survey of Child Oral Health Revised Items and Reasons for Revision

Cognitive Interview Items	Cognitive Interview Revisions	Field Survey Items
6a) My Child’s Teeth Are:  Bright white  Some Yellow  Some Green  Some Brown  Some Black	Some parents did not know how to report the color of their children’s teeth and were confused by “bright white”; a couple of parents had their children’s teeth brightened by dentists, but most of the others felt either “white” or “yellow” was more like the color; however, some had a brown tooth among the other colors. Given the option to include different colors seemed to solve the problem.	The color(s) of my child’s teeth are (check all that apply):  Some bright white  Some white  Some yellow  Some green  Some brown  Some black  Total
6b) My child’s teeth are:  Straight no spaces  Straight with spaces  Crooked or Crowded	The following comments raised the issue of upper arch vs. lower arch; this could add information, but complicates the response. However, allowing parents to respond to multiple individual items such as: straight, spaces, crowding and crooked, would increase the respondents’ ability to characterize aesthetic and occlusal aspects. The “straight with spaces” response is less important in the younger ages than in the adolescent. Responses included: “many are straight but there are some crooked, but none are crowded”; “straight but with spaces for the upper teeth and crooked and crowded for the lower teeth”; “child’s teeth were crooked or crowded and at the same time there were spaces.”	My child’s teeth (check all that apply):  Are straight  Have spaces  Are crooked  Are crowded  Total
6c) When I look at my child’s teeth:  I am happy with how they look  I feel that they could look better  I am unhappy with the way they look	Parents were either happy or felt they could look better, mainly because of teeth that are crooked or crowded, to a lesser degree because of color or cavities. We changed the response from “happy/unhappy” to “fine”/“a little better”/“a lot better.” Responses included: “They could look better because of crooked teeth”; “they could look better because they were crooked and had spaces”; “they could look better because of cavities in primary teeth”; “they could look better because of crowding and color”; “they could look better after the braces close the spaces.”	When I look at my child’s teeth:  They look fine  They could look a little better  They could look a lot better  Total
6d) Bad breath for my child is:  Always a problem  Sometimes a problem  Never a problem	Most parents did not think this was a problem. Some made reference to “morning breath,” i.e., “in the mornings when she wakes up”; or “when he gets home from school.” One parent said: “Always has bad breath” We added a question to address parents’ concern about their child’s bad breath: ‘How often does your child have bad breath? Another item was added that focuses on parental concern’.	How often does your child have bad breath?  Always  Almost always  Often  Sometimes  Almost never  Never  Total
	Originally, this was one item in the cognitive interview; however, we chose to create two separate survey items to better explain which parents noticed the problem and their level of concern.	How often are you concerned about your child’s bad breath?  Always  Almost always  Often  Sometimes  Almost never  Never  Total
6e) Did your child ever refuse to go to a dentist because s/he was afraid of:  Getting needles  Having your teeth pulled  Drillings  Having to keep your mouth opened for a long time  Gagging or choking  The child feeling numb  I didn’t like the dentist  The child getting sick from the treatment	The temporal issue was resolved by asking parents to respond in terms of the present rather than “ever.” The wording “refused” confused the issue, because it is the parent’s responsibility for accessing care; the question was changed from “refused” to “being afraid of.” The term, “refuse,” gives the child agency, whereas “afraid” is amenable to parents talking about fear. We do not wish to imply that the child has autonomy or the freedom to dictate dental treatment or refuse care. Responses included: ‘Getting needles, drilling, gaging, my dentist’ “when 4 years old went to a dentist who wasn’t good with children, now fine”; “the dentist wasn’t good, the present one is”; and “not a problem now” ‘checked getting needle and drilling’	What is your child afraid of? (Check all that apply)  None selected  He/she dislikes needles  He/she is afraid of having teeth pulled  He/she dislikes drilling  He/she dislikes keeping my mouth opened for so long  He/she is afraid of gagging or choking  It was a new experience  He/she dislikes feeling numbness  He/she is afraid of the dentist  He/she is afraid of feeling sick  He/she is afraid of the mask and glove  Total
6f) Did your child ever worry about problems with his/her teeth?  Yes: What did s/he worry about?  No  Teeth are going to give him or her pain  Decayed or rotten teeth  Teeth that don’t look good  Teeth that are going to fall out  Other	The new version allowed for parents to check all that applied and added “pain with teeth,” rather than only “teeth” and “bad breath.” Parent responses included: “decayed teeth and decayed that don’t look good due to color”; ‘decayed and rotten teeth and teeth that don’t look good’; “decayed and rotten teeth”; ‘getting needles, drilling, gagging and my dentist’; and “when was four old went to a dentist who was good with children, now fine.”	Does your child worry about problems with his or her teeth? Yes/No What does he or she worry about? Check all that apply. (Check all that apply) Yes (see responses below) No Pain with his/her teeth Decayed or rotten teeth His/her teeth don’t look good His/her teeth are falling out Bad breath Other, please explain Total
6 g) Good oral health is important to my child’s overall health.  Disagree  Agree somewhat  Strongly agree	Many parents believed that there is a link between poor oral health and systemic disease. The question was not changed in this case. The response categories were increased by adding "disagree somewhat," which provides more balance.	Good oral health is important to my child’s overall health.  Disagree Strongly  Disagree Somewhat  Agree somewhat  Agree Strongly  Total
6 h) If I don’t help my child care for his/her teeth, his/her life will be:  Shorter by many years  Shorter by a few years  About the same	The comments regarding teeth and longevity came from several Latino parents who saw a direct link between the number of teeth and the years of life. This link opened our eyes to the issue of health over the life course. The question was put in the positive and the response was made comparative; rather than a simple “shorter by many years,” we changed it to “many more years than if I didn’t take care of them”	If I help my child care for his or her oral health, he or she will live:  Many more years than if I didn’t take care of them  Somewhat more years than if I didn’t take care of them  The same number of many of years than if I didn’t take care of them  Some fewer years than if I didn’t take care of them  Many fewer years than if I didn’t take care of them  Total
6i) If my child maintains good oral health, s/he will have a better chance of getting into college and having a successful career.  Disagree  Agree somewhat  Agree strongly	Parents found this question confusing because they did not view oral health as important to getting into college. They saw that process as impersonal, namely relying on data, such as the GPA, SAT/ACT scores and recommendation letters, and not the direct contact with the admissions decision-makers. By contrast, parents regarded a career as a personal process involving direct interaction where oral health plays a more important role. As a result, we decided to relate oral health to chance of success in life.	If my child maintains good oral health, he or she will have a better chance of success in life.  Disagree strongly  Disagree somewhat  Agree somewhat  Agree strongly  Total
6j) When my child had a recent oral health problem:  I was able to take care of it myself  I could not take care of it myself and let it go at that  I could not take care of it, and sought dental care  My child did not have a recent oral health problem	This was not an open-ended question, but one that is factual.	During the last 12 months, did your child have an oral health problem  Yes (check all that apply)  No  I was able to take care of it myself without going to the dentist  I did not do anything about it  I took my child to the dentist  Total
6 k) I am able to make a difference to my child’s oral health  Disagree  Agree Somewhat  Agree Strongly	Rather than using the term, “make a difference,” efficacy was better reflected by the action term “prevent oral health problems”; two responses, “Disagree strongly” and “Disagree somewhat” replaced “Disagree,” to provide more balance in the response categories.	I can do many things to prevent oral health problems in my child.  Disagree Strongly  Disagree somewhat  Agree somewhat  Agree strongly  Total
6 l) Before my child goes to sleep, I remind him/her to brush:  Always  Sometimes  Never	We changed the question to address our expert panel, whose members preferred a conceptual approach, rather than a strictly behavioral one. The previous version asked the extent to which the parent had to remind the child (behavior), while the revised version asked about the parent’s belief in the effectiveness of reminding the child to brush. This necessitated a change in responses to: “…make his/her oral health better”; “…keep his/her oral health the same”; ‘…make no difference in his/her oral health’.	By reminding my child to brush his or her teeth, I believe:  It will make his/her oral health better  It will keep his/her oral health the same  It will make no difference to his/her oral health  Total