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J Am Dent Assoc, Vol 136, No 3, 364-372.
© 2005 American Dental Association
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TRENDS

JADA Continuing Education

Parental perceptions of their preschool-aged children’s oral health



BHAVNA S. TALEKAR, B.D.S., M.P.H., R. GARY ROZIER, D.D.S., M.P.H., GARY D. SLADE, B.D.Sc., D.D.P.H., Ph.D. and SUSAN T. ENNETT, M.S.P.H., Ph.D.


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Parents have an important role in making decisions about their children’s oral health. The purpose of the authors’ study was to determine parental perceptions of their children’s oral health status and factors correlated with these perceptions of health.

Methods. The authors analyzed data for 3,424 children (2–5 years of age) from the Third National Health and Nutrition Examination Survey. They based the dependent variable on a question asked of primary caregivers: "How would you describe the condition of [child’s name]’s natural teeth?" Explanatory variables included demographic variables, dental visits, perception of child’s general health, need for dental care and presence of tooth caries.

Results. Eighty-nine percent of parents rated their child’s oral health as excellent, very good or good, and 11 percent rated it as fair or poor (mean = 2.7 on a five-point scale, with 1 being excellent and 5 being poor). Tooth caries, perceived need for dental cleaning and treatment, lower income and poorer general health perceptions were associated with poorer parental ratings.

Conclusions. Actual disease and perceived need are associated significantly with parents’ perceptions of their children’s oral health.

Practice Implications. Understanding parents’ perceptions of their children’s oral health and factors that motivate these perceptions can help dentistry overcome barriers that parents encounter in accessing dental care for their children.

Key Words: Parents; perceptions; preschool-aged children; dental care

Parents usually are the primary decision makers on matters affecting their children’s health and health care.1,2 Therefore, parents, along with clinicians, play a key role in attempts to achieve the best oral health outcomes for their young children. Considering parents’ central role in ensuring the well-being of young children, it is important to explore their perceptions about their children’s oral health. These perceptions can affect the preventive dental care children receive at home and their use of professional dental services.3 Parents’ assessments also can provide some indication of children’s need for professional dental care, which, in turn, has implications for the formulation of dental health policies.4 Moreover, understanding factors associated with parents’ perceptions about their children’s oral health may help the dental community understand some of the reasons why children do not receive the dental care they need. These considerations are especially important for preschool-aged children because their inability to verbalize their emotions and distress increases their dependence on adults. Parental characteristics and beliefs thus may be an important consideration in attempts made to improve preschool-aged children’s oral health.

Understanding parents’ perceptions of their children’s oral health can help dentistry overcome barriers that parents encounter in accessing dental care for their children.

Research on oral health perceptions has focused on school-aged children5 and adults.6,7 However, no population-based study has reported parents’ perceptions of the oral health of children younger than 6 years of age. A few studies8–10 have explored parents’ assessments of their children’s general health. Results from these studies suggest that parents’ social demographic characteristics can affect their perceptions about their preschool-aged children’s health. Mothers living in poverty and belonging to minority groups are more likely to report the general health of their children to be worse than are nonminority mothers who are not living in poverty. Importantly, parents’ global ratings of their children’s health are associated with the presence of acute and chronic disease.9

Studies among adults have used a behavioral model that considers one’s social demographic characteristics in combination with beliefs, perceptions of disease and the presence of disease as major factors contributing to perceptions about one’s oral health.6,11,12 Gift and colleagues6 found that almost two-thirds of U.S. adults considered their natural teeth to be in excellent, very good or good condition. Those who rated their teeth as being in poor condition had more missing teeth, carious teeth and periodontal disease compared with adults who rated their oral health as excellent. When the authors controlled for clinical status, they found that oral health was rated worse by those who were older, were minorities, were economically disadvantaged, reported the need for more dental care and perceived their general health to be poorer.

Similar associations for adults’ assessment of their children’s oral health have not been investigated in detail. However, factors identified in studies of adults might affect not only perceptions of their own oral health, but also their perceptions about their children’s oral health. We conducted a study to examine such associations to better understand the nature and correlates of parents’ perceptions of their preschool-aged children’s oral health.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
In this study, we explored the relationships between the characteristics of parents of children aged 2 to 5 years and the parents’ assessments of the children’s oral health, using data from a cross-sectional national survey. We hypothesized that parents’ characteristics, beliefs and subjective assessments of their children’s need for dental care, along with the children’s social demographic characteristics and actual dental disease status, would be correlated with parents’ perceptions about their children’s oral health.

Data source and analytical sample. The data we used in this study were from the Third National Health and Nutrition Examination Survey (NHANES III), which was conducted during the period 1988 through 1994. NHANES III was based on a multistage probability sample of the noninstitutionalized civilian population aged 2 months and older residing in the 50 states. Further details about NHANES III and the oral health component of this survey are reported elsewhere.13–15

We obtained the analytic sample of 2- to 5-year-olds by merging the Household Youth and Examination data files. The Household Youth data file contains responses to questions asked of primary caregivers, and the Examination data file contains information pertaining to children and youth (0–18 years) who underwent a complete physical examination, including a dental examination. In NHANES III, children 23 months of age and younger did not receive a complete examination for dental caries and, thus, we excluded them from our study.16

Preliminary examination of data revealed many missing values for two key variables: the need for dental treatment and preventive services. Of the 4,300 children 2 to 5 years of age who had dental examination results, 3,424 (79.6 percent) had complete information. As children with partial information did not differ from those with complete information with respect to their social demographic characteristics (age, sex, race/ethnicity, education of adult family member, family income, family size, mother’s country of birth, urbanization classification or region of country), we included only children with complete data in our analyses.

Variable construction. We based the dependent variable on the question asked of the primary caregiver: "How would you describe the condition of [child’s name]’s natural teeth?" Answers were recorded using a Likert scale with response options coded 1 through 5 (excellent = 1, very good = 2, good = 3, fair = 4, poor = 5).

Three variables captured parent-defined beliefs about their children’s dental and medical health status and needs. Parent-defined need for dental care included two variables: perceptions of need for dental treatment and need for cleaning teeth. The need for treatment variable was a dichotomous variable constructed from responses to five questions that asked parents if they felt their children needed to "have teeth filled or replaced, teeth pulled, gum treatment, relief of pain or dental work to improve appearance." A positive response to any of the five questions was coded as a yes; otherwise, answers were coded as a no. Parental perception of need for cleaning was a dichotomous variable (yes, no) that indicated whether the parent felt that his or her child’s teeth needed cleaning.

Because of extensive evidence of strong correlations between perceptions of general health and oral health among adults,6,7,17–19 we explored whether parents made similar associations when reporting their children’s health. We derived parental perceptions of children’s general health from a question that asked the parent to rate his or her child’s general health on a five-point scale (1 = excellent, 2 = very good, 3 = good, 4 = fair and 5 = poor). We combined the fair and poor categories, as there were a small number of responses in the poor category.

We determined a child’s dental health status by the presence or absence of carious tooth surfaces. We calculated and converted a count of carious tooth surfaces into a dichotomous variable (0, ≥1) that indicated whether the child had any untreated dental caries.

The social demographic characteristics in our study included parent, child and family variables. Parental characteristics included parents’ education (less than high school, high school or more than high school) and mother’s country of birth (United States versus Mexico/other). Child demographic characteristics included the child’s age in individual years (ages 2 to 5 years), sex and race/ethnicity (non-Hispanic black, non-Hispanic white, Mexican-American, other). Family characteristics included family income as a percentage of the federal poverty line (FPL) (0–100 percent, 101–200 percent, 201–300 percent and more than 300 percent of FPL), family size (up to four people, five or more people), urbanization classification (metropolitan area, non-metropolitan area/other) and region of the country (Northeast, Midwest, South, West).

We also considered the child’s insurance status. Having insurance increases the likelihood that a child will receive professional dental care,20 and the resulting dental visit might affect dental health perceptions.6 However, because of limitations imposed by the data set, we were unable to include a dental insurance variable. We were able to include variables that measured participation (yes, no) in two public assistance programs: the Food Stamp Program and the Special Supplemental Nutrition Program for Women, Infants and Children. These two variables likely identified a large percentage of study subjects who lacked private insurance and were covered by Medicaid.

Parents of children who have visited a dentist differ from parents of those who have not, according to important social demographic characteristics such as being better educated and having higher income.21,22 Furthermore, a visit to the dentist can result in the provision of care and the alleviation of symptoms, with the potential for an impact on parents’ perceptions.6 For this reason, we examined parental perceptions among those who had used dental care for their children and those who did not use such care. The question about dental visits asked the parent how long ago the child had visited a dentist or dental hygienist preceding the interview. We created a dichotomous variable indicating whether the child had ever visited a dentist or dental hygienist.

Analysis strategy. We used preliminary descriptive analyses to assess the distribution of responses for all study variables. We set a minimum cell sample size at 30 in deciding whether to collapse categories of variables.23 We evaluated overall associations between the dependent and explanatory variables using {chi}2 tests when the dependent variable was categorical, and one-way analysis of variance when the dependent variable was linear.

We estimated linear regression models to examine the correlates of parents’ perceptions of their preschool-aged children’s oral health. The dependent variable was the five-point, ordinal rating of children’s dental health. We used linear regression models in preference to other models, such as ordinal logistic regression, to maintain consistency with the methodology used by Gift and colleagues.6 Furthermore, global ratings of health made on Likert-type scales are known to yield a continuum from excellent to poor.24 We created dummy variables for all explanatory variables with more than two response categories to allow for interpretation of the marginal effects of variable categories. We used correlation coefficients and tolerance to examine for multi-collinearity.25,26 We entered all explanatory variables into the linear regression model at the same time.

Because social demographic characteristics acting in combination can shape people’s life experiences and may affect their health perceptions,27 we examined the joint effect of these variables, in addition to each of their effects. For this purpose, we used the F statistic to test for multiple exclusion restrictions. We also conducted regression analysis that was conditional on the child’s past dental visits to determine if parental perceptions were modified by dental use. We conducted all multivariate analyses using statistical software (SUDAAN, Release 8.0, Research Triangle Institute, Research Triangle Park, N.C.) that was able to accommodate the complex sampling design used in NHANES III.26


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The average age of children in the sample was 2.5 years. A total of 48.4 percent of the children were girls, 64.0 percent were white, 16.0 percent were non-Hispanic black, 9.1 percent were Mexican-American, and 10.9 percent were from other racial groups; the sample was distributed almost equally across all family income categories. These and other social demographic characteristics of the sample are presented in Table 1Go. In addition, 50.6 percent of the children had never visited a dentist, and 19.0 percent had one or more carious tooth surfaces.


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  		TABLE 1 WEIGHTED PERCENTAGE OF THE STUDY SAMPLE FOR SELECTED DEMOGRAPHIC CHARACTERISTICS.

 
A total of 89.1 percent of the parents rated their children’s oral health as excellent, very good or good (FigureGo). The mean for this variable was 2.1 (standard error of the mean ± 1.2), a rating between very good and good (Table 2Go, page 369). All variables were associated with the mean perception ratings at a statistically significant level in the bivariate analysis, except for the child’s sex and past dental visits (Table 2Go). Parents who perceived no need for their child to have dental treatment or have their teeth cleaned, perceived their child’s general health to be better and those who had children with no dental caries tended to rate their child’s oral health better. In addition, lower income parents and those with less than a high school education rated their children’s oral health worse than parents with higher income and more education did.


Figure 1
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  		Figure. Parents’ ratings of their preschool-aged children’s oral health.

 

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  		TABLE 2 RESULTS OF BIVARIATE ANALYSIS.

 
Results of the regression analysis for the entire sample are presented in Table 3Go (page 370). Parents believed their children’s oral health to be worse if they perceived the need for treatment or preventive dental care for their children, they had lower family incomes compared with the highest income category, or they perceived their children’s general health to be worse than excellent. Parents perceived their child’s oral health to be better if the child had no carious tooth surfaces and if he or she was younger than the reference age of 5 years. The parent, child and family social demographic variables were jointly significant (F statistic = 5.32; P = .01). The full model explained 43 percent of the variance in the dependent variable.


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  		TABLE 3 RESULTS OF REGRESSION ANALYSIS OF ALL INDEPENDENT VARIABLES ON PARENTAL PERCEPTIONS OF CHILDREN’S ORAL HEALTH.*

 
Table 4Go (page 371) shows the results for variables significant in the stratified analysis. When we stratified the sample on dental visits, presence of tooth caries, parental perception of the child’s need for dental treatment and parental perception of the child’s general health continued to be associated with perceptions of their child’s oral health status in both models and in the same direction as that in the full model. However, parental perception of the child’s need for preventive dental care and family income were associated with the outcome variable only in the model for those children who had not had a dental visit. In addition, living in an urban area contributed to poorer parental ratings of their child’s oral health status.


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  		TABLE 4 CORRELATES OF PARENTS’ PERCEPTIONS OF THEIR CHILDREN’S ORAL HEALTH, STRATIFYING ON VISITS.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Similar to adults’ ratings for themselves, most parents rated their children’s oral health positively. Furthermore, many correlates of parents’ perceptions of their children’s oral health in our study are similar to those reported for adults’ perceptions of their own oral health in other studies.6,19 In our study, parents belonging to minority and economically disadvantaged groups and with less than a high school education were overrepresented in the poor perception category. Our finding of the significant joint effect of social demographic variables included in our study on perceptions provides additional evidence of the impact of individual life situations on parents’ oral health perceptions for their children. It appears that parents with poorer perceptions of their children’s oral health also were the ones least likely to be able to access dental care for their children.28–30 Thus, the correlates of barriers to parents’ access to care for their children and those for poor parental perceptions appear to overlap.

Results also suggest that many parents maintain accurate assessments of their children’s oral health status. Presence of untreated dental caries in the children and perception of need for treatment were associated with parents’ perceptions that their children’s oral health was poorer, irrespective of past dental visits. Poorer perception of their children’s oral health thus may reflect the unmet need for dental care among these children. This finding suggests that barriers other than parental perceived need for dental care are preventing low-income children from gaining access to dental care at an early age. For public health purposes, parents’ assessments of their children’s oral health could be incorporated into population-based surveys that attempt to assess preschool-aged children’s need for dental care. Resulting information can provide valuable input in planning and resource allocation for dental health services.

The inverse gradient we observed for the relationship between the children’s increasing ages and declining parental perception of their children’s oral health likely reflects on the cumulative effect of dental disease on the children. Conversely, better perceptions of their children’s oral health among parents of younger children, when we controlled for the children’s disease status, suggest that parents may not consider poor oral health as a possibility for younger children. This finding has important implications as far as recommendations for age at first dental visit. It suggests that more effort needs to be put into educating parents about the importance of having their children visit a dentist even when the children are very young.

Our finding of a strong correlation between general and oral health perceptions is consistent with studies involving adults.6,17,18,31 Results suggest that parents make similar associations when responding for their children. Although we cannot draw any inferences about the direction of this relationship, this finding by itself underscores the importance of making oral health services a part of general health services for young children.

Parental assessments of the oral health of their children indicate parents’ perceived risk of their children’s susceptibility to dental disease. Our results show that clinical disease, parent-defined need for dental treatment and perceptions of poor oral health coexist in these young children. Clinicians’ awareness of parents’ perceptions of their children’s oral health and factors motivating these perceptions may better enable them to affect the oral health and the dental-related quality of life of their patients positively.3 Understanding factors that affect parents’ perceptions of their children’s oral health can move dentistry closer to developing strategies to help overcome the barriers parents encounter in accessing oral health care for their children. In turn, this understanding may enable parents to be partners with health care providers in ensuring the well-being of their children.

This study had two major limitations that affected the interpretation of the results. First, its cross-sectional design limited inferences of cause and effect. We were unable to know, for example, if the child’s dental disease status caused the parent’s perceptions of his or her child’s oral health or whether these perceptions were held for other reasons. Longitudinal studies would help greatly in clarifying these relationships.

The second major limitation was that we did not have access to some important information, which could have led to information bias. We were unable to use the dental insurance variable in NHANES III because the method of asking for this information changed over the course of the survey. We also lacked important information on parents. Parents’ health beliefs and attitudes toward dental care for themselves are significant predictors of children’s dental care utilization.32 Because the public use youth and adult data files of NHANES III cannot be merged, we were unable to include such information. Nevertheless, our use of a large national survey allows for the first-ever reporting of parents’ assessment of their preschool-aged children’s oral health.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Because children younger than 8 years of age likely are unable to recall details of events important to their health beyond 24 hours,33 practitioners must depend on parents for providing an assessment of their child’s health status. Dental disease and treatment need are associated with parents’ perceptions of their children’s oral health. Therefore, correlates of these perceptions can be important indicators of parent, child and family characteristics that may impede or facilitate children’s use of dental care services.


   FOOTNOTES
 

Dr. Talekar is a doctoral student, Department of Health Policy and Administration, The University of North Carolina at Chapel Hill, McGavran-Greenberg Hall, CB#7411, Chapel Hill, N.C. 27599-7411, e-mail "talekar{at}email.unc.edu". Address reprint requests to Dr. Talekar.


Dr. Rozier is a professor, Department of Health Policy and Administration, School of Public Health, The University of North Carolina at Chapel Hill.


Dr. Slade was an associate professor, Dental Ecology, The University of North Carolina at Chapel Hill, School of Dentistry, when this article was written. He now is a professor of oral epidemiology, Dental School, The University of Adelaide, Australia.


Dr. Ennett is an associate professor, Department of Health Behavior and Health Education, School of Public Health, The University of North Carolina at Chapel Hill.


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 CONCLUSIONS
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