Nor Hassan Sadek
Fifth year, group 15PARENTAL PERCEPTION OF CHILDREN’S ORAL
HEALTH AT A MIDDLE EASTERN SCHOOL IN WEST
LONDON
Master’s thesisSupervisor Dr, Sandra Žemgulytė
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC FOR PREVENTIVE AND PEDIATRIC DENTISTRY
PARENTAL PERCEPTION OF CHILDREN’S ORAL HEALTH AT A MIDDLE EASTERN SCHOOL IN WEST LONDON
Master’s Thesis
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TABLE OF CONTENTS
SUMMARY……….……….……...8
INTRODUCTION……….…………..9
REVIEW OF LITERATURE…….……….…….…...11
MATERIAL AND METHODS………....……...14
RESULTS………...15 DISCUSSION………....…………....20 CONCLUSION………...………….….….23 ACKNOWLEDGEMENT………..……….…..23 CONFLICT OF INTERESTS………..………..23 PRACTICAL RECOMMENDATIONS………...23 REFERENCES………....………...24 ANNEXES……….…28
PARENTAL PERCEPTION OF CHILDREN’S ORAL HEALTH AT A MIDDLE
EASTERN SCHOOL IN WEST LONDON
SUMMARY
Aim: To evaluate the attitude and awareness of children’s oral health among Middle Eastern parents with children attending a Saturday school in west London
Material and methods: The survey was conducted in a private school, Ikhlass School, in west
London. A self-administered questionnaire was designed to evaluate parental attitude and awareness of children’s oral health and enquired about demographic characteristics, parental attitude and behaviour and dietary habits of children. The participants were 304 parents/guardians with a mean age was 44.1 (9.46) years. The data was analysed using SPSS, version 19. The level of significance was set at P<0.05.
Results: 52.30% of children brushed their own teeth, especially those of parents with no formal
education (p=0.004). Significantly more parents with primary school and university education reported that children’s teeth are brushed for up to 2 minutes (p<0.001). 63.49% of the parents did not use any other auxiliary method to clean their child’s teeth. 53% of children occasionally experienced toothache or discomfort in the past 12 months. 70.40% of the children drink milk/hot drink with sugar least once a day.
Conclusion: The attitude and awareness of parents/guardians regarding the children’s oral health is insufficient. Reported oral hygiene behaviour was more favourable in children whose parents had a higher education level (secondary and university). Two third of parents use fluoridated toothpaste and the majority of parents did not use any other auxiliary method to clean their child’s teeth.
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INTRODUCTION
Oral health is a vital component of general health and it cannot be ignored as it could affect an individual’s ability to taste, smile, swallow and chew, speak [1].
Parents are an important model for their children in regards to oral health as both good and inadequate oral hygiene habits are transferred from parents to children [2]. The decisions made by parents greatly affect the well-being of their children and therefore parents play a major part in making sure that their children receive oral and medical healthcare. [3].
According to the World Health Organization 60–90% of school children worldwide are affected by dental caries [1]. A national dental health survey in the United Kingdom established that almost a third (31%) of 5-year olds and approximately half (46%) of 8-year olds experienced dental caries in their primary teeth [4].
Chronic pain from decayed teeth can remarkably affect a child’s wellbeing which, in turn, has
significant consequences on family life [5]. As a result of pain, the child’s ability to develop and learn is impacted due to disturbed sleep and eating difficulties [5]. This will affect the family as, for example, parents could be wakened at night and children may possibly miss school days due to toothache or the need of dental treatment which means that parents need to take time off work to take their children to the dentist [5]. Also, missing school or having behaviour changes as a result of dental pain will affect the child’s learning at school [5].
Dental caries may be a primary symptom of wider health issues such as obesity and poor nutrition which, in some cases, could indicate child neglect [6]. Dental neglect is the parent’s constant failure to ensure that their child is free from pain and infections by providing the required dental treatment to maintain the oral health of their child [7, 8]. Research has found that dental neglect among parents resulted in poorer oral health of children [9].
Despite the improvement in children’s oral health over the last 50 years due to the broad use of fluoride, dental caries remains a problem which excessively affects individuals with lower
socioeconomic status [6]. It has been found that parental socioeconomic characteristics influence dental caries [10] and oral health related quality of life in children [11]. Families of lower social class or lower income were associated with higher prevalence or of dental caries [10]. Determining the factors which are associated with the perceptions of parents about the oral health of their children can aid medical and dental primary care providers to understand why children do not obtain the dental care needed in their households or from health care providers and this could partly bring some clarity as to why children
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occasionally do not receive the needed treatment unless the disease has developed enough to require surgical treatment [12].
Hypothesis:
We expect parental attitude and awareness of children’s oral health among parents to be adequate and it may differ according to the parental education level.
Aim:
To evaluate the attitude and awareness of children’s oral health among Middle Eastern parents with children attending a Saturday school in west London.
Objectives:
1. To describe the parental awareness and attitude towards oral hygiene habits in regards to their educational level.
2. To describe the parental awareness and attitude towards dietary habits in regards to their educational level.
3. To analyse the literature sources related to the study and compare the results with the findings of this study.
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REVIEW OF LITERATURE
In literature, various studies have evaluated the attitude and awareness of parents in regards to the oral health of their children and it has been found that the oral health condition of children is influenced by the oral health behaviour of their parents [2]. The oral health behaviours established by children in their early years are usually maintained and related to their oral health conditions later in life [5, 6].
Daly et al. studied the factors associated with parental perceptions of how well they do in taking care of the infants’ teeth and/or gums. Several factors were found to be associated with parental perceptions of taking care of their children’s teeth/gums including demographic characteristics, daily brushing, toothpaste usage, dental visit consistency and dietary habit. It was concluded that the parents who indicated poor dental health for themselves and their infants perceived that they took care of their children’s teeth and gums poorly. Likewise, parents who ensured oral healthcare, i.e. brushing teeth daily with fluoridated toothpaste, avoiding food after brushing teeth at night and having regular dental examinations, perceived they took good care of their children’s teeth [3]. Similarly, a study by Sohn et al. reported that parents’ perceptions are a good indicator of their children’s oral health, for example, the mean number of cavitated lesions was 81 times higher in children of parents who reported their children oral health as “poor” than in those of parents who reported their children’s oral health as “excellent” [13].
Nadazdyova et al. conducted a survey study to analyse parental knowledge about the hygiene habits of their children. In this study, 95.4% of the parents reported that their children brush their own teeth and 35.5% of the parents had never received any information regarding the maintenance of their child’s oral hygiene. The results of this study show that the parents did not have clear information about the oral health of children and the authors concluded that it is vital to educate parents about oral hygiene as they are the decision makers for their children and would decide what dental tools should be used, as well as the frequency of tooth brushing [14]. Likewise, ElKarmi et al. evaluated the knowledge and behaviour of parents about the oral and dental health of their children. The results noted deficiencies in oral hygiene practices. Only a minority of parents brushed their child’s teeth. Approximately half of the parents believed that the information available to them about their children’s oral health was
insufficient. The authors concluded that the parents have inadequate knowledge about the oral health of their children. Based on the results of this article, the authors suggest the need for improvement in the parental education, particularly in tooth brushing behaviour and use of toothpaste [15].
Dental neglect by parents among children in the study by Gurunathan et al. was evaluated and related to the oral health status of the children aged between 3 and 12 years of age. The parents were asked to
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respond to a questionnaire whereas the children had their oral cavity examined during which their oral health status was assessed using oral hygiene index, decayed, extracted, filled teeth (def(t)), pulp, ulcers, fistula, abscess (pufa), decayed, missing, filled teeth (DMFT), PUFA as per the World Health Organization criteria and pufa/PUFA index. The study showed that the dental neglect score is higher in caregivers aged above 30 years. Additionally, the results showed a significantly higher dental neglect score among parents who had completed secondary school compared to parents who had graduated university (p<0.001), showing that education plays a significant part in parent’s knowledge and attitude towards adequate dental care. Furthermore, this dental neglect resulted in poorer oral health of children [9]. Another study by Lourenço et al. was conducted to analyse the relationship between dental caries and neglect; the authors concluded that there is a relationship between caries experience and parental perceptions of children’s oral health [16].
A study by Wigen et al. aimed to explore a relationship between avoidance behaviour in both parents and children and caries experience in children. Data were collected from dental records and dental examinations of children as well as from a questionnaire completed by the parents. It was found that children with one or more missed dental appointments were associated with dental caries and were four times more likely to experience caries than children with no missed dental appointments. The authors stated that parents are responsible for ensuring that their child attend scheduled dental appointments and therefore, missing dental appointments implies that the parents have negative beliefs and attitudes toward dental care. The authors concluded that parents who avoided bringing their child to scheduled dental appointments increased the child’s risk of experiencing caries [17].
One survey study by Saldūnaitė et al. aimed to show attitudes of parents toward the dental healthcare of their children and the preventive measures used in addition to evaluating their relationship with
parental education and socioeconomic status. The result showed that more care about oral hygiene education and regular dental examinations was shown by the parents with higher education level and the parents with adequate income. Also, the children of parents with high education level brushed their teeth more frequently than the children with low education level. Moreover, the obtained data showed that 98.5% of the children used fluoridated toothpaste but only 21.8% used dental floss. The authors concluded that more attention into children’s dental care was given by parents with high education level and adequate income [18].
The purpose of the study by Jacobsson et al. was to present data on the sociodemographic conditions, knowledge of dental diseases, dental care, and dietary habits among children. A questionnaire was completed by the parents of 3 and 5-year olds, and a modified questionnaire was given to 10 and 15-year olds to complete by themselves. The results showed that 70-80% of children consumed sweets
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between meals. Approximately half of the children consumed cakes and candy at least once a day and 71% of 3-year olds and 91% of 5-year olds consumed milk with sugar regularly. The conclusion of this study was that children consumed sugar frequently; however, the frequency of tooth brushing with fluoridated toothpaste was deficient. Therefore, the authors recommend parental education about oral health to improve children’s oral health [19].
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MATERIAL AND METHODS
The survey was conducted from November 2017 to January 2018 in the capital of England, London, with a population of approximately 8,674,000 people [20]. There are 4 private Saturday Arabic schools with approximately similar numbers of pupils in west London. The study was carried out in one school called Ikhlass School. A self-administered questionnaire was distributed by one teacher (EA) to 304 parents, who had children aged between 5 to 13 years.
The questionnaire was prepared by the investigator in English and the questions were designed to evaluate the attitude and awareness of children’s oral health among Middle Eastern parents with children attending a Saturday school in west London. The questionnaire consisted of three parts; the first part included questions about demographic characteristics (age of parents/guardian, education level of parent, the age and gender of their child and number of the children in their household), the second part of the questionnaire (9 questions) was about the attitude and behaviour of parents in regards to the children’s oral health (history of recent toothache, frequency of dental visits) and oral hygiene habits (tooth brushing, auxiliary methods of tooth cleaning), and the third part involved the dietary habits of the children.
The 304 respondents consisted of 218 mothers, 59 fathers and 27 guardians aged between 27 to 68 years old. The mean age was 44.1 (9.46) years.
The response rate was 100% due to the participant’s high awareness and willingness to participate.
The data obtained was computerised, coded and analysed using the Statistical Package for the Social Sciences (SPSS) program, version 19. To establish relationships between categorical variables, the Pearson chi-squared test (χ2) was used. The level of significance was set at P<0.05.
Ethical approval was obtained from the bioethics department in Lithuanian University of Health Sciences (Reference no. BEC-OF-53). Participation was voluntarily and anonymity was ensured for all respondents.
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RESULTS
Overall 304 participants filled the questionnaires. A higher number of mothers (71.70%) answered the questionnaires than fathers (19.40%) and guardians (8.90%). The most prevalent age group of parents was 37-46 years (34.80%). Almost a third of the participants had completed secondary school (33.60%) while 29.30% were college/university graduates. The most prevalent age group of children was 5-9 years (72.70%). Families with 2 or 3 children were the most common (53.30%). Furthermore, there were higher number of female children (63.20%) compared to male children (36.80%) (Table 1).
Table 1. Demographic data of participants.
Variable Frequency (N) Percentage (%)
Respondent Mother 218 71.70 Father 59 19.40 Guardian 27 8.90 Age of respondent ≤36 77 25.40 37-46 106 34.90 47-56 90 29.50 57≥ 31 10.20 Education level No formal education 55 18.10 Primary school 57 18.70 Secondary/high school 102 33.60 College/university 90 29.60 Gender of child Female 192 63.20 Male 112 36.80
Age of child (year)
5-9 221 72.80
10-13 83 27.20
Number of children in household
1 111 36.50
2-3 162 53.30
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In regards to the children’s oral hygiene habits, 84.54% of the children brushed their teeth at least twice a day, out of these children 27.30% had college/university educated parents in comparison to 14.14% with parents of no formal education, however, there was no statistically significant difference between the parental education levels (p=0.088) (Table 2).
More than half of the children (52.30%) brushed their own teeth and of those, significantly more children (67.3%) had parents with no formal education (p=0.004). Meanwhile 45.07% of participants reported that they brush their child’s teeth and significantly more parents or guardians were with secondary school education (p=0.004).
A greater number of parents (49.34%) answered that their child’s teeth are brushed for up to 2 mins whereas 40.46% reported that their child’s teeth are brushed for at least 2 mins. Considering the parental education level, significantly more parents with primary school and university education reported that their children’s teeth are brushed for up to 2 minutes (p<0.001) (Table 2).
Furthermore, most parents (66.78%) use fluoridated toothpaste and significantly more parents with university education (83.3%) preferred this type of toothpaste (p<0.001).
63.49% of the parents did not use any other auxiliary method to clean their child’s teeth and only 10.89% reported using dental floss. Significantly more parents with no formal education (70.9%) did not use any auxiliary method for their child’s oral hygiene (p=0.019).
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Table 2. Relationship between parental education level and children’s oral hygiene habits.
The results show that more than half of the children (53%) occasionally experienced toothache or discomfort in the past 12 months. A majority of these children (57.8%) had parents with a
college/university degree (p=0.001).
22.04% of parents reported that their children did not complain about toothache in the past 12 months and most of them had completed secondary school or university (p=0.001). Additionally, routine dental examinations were the most prevalent reason for dental visits for those parents (30.92%) and 20.72% of
Variable Parental education N (%) Total N (%) P-value No formal education Primary school completed Secondary school completed College/ university completed Frequency N (%) Frequency of tooth brushing
≥Twice 43(14.14) 48 (15.79) 83 (27.30) 83 (27.30) 257 (84.54)
0.088 Once a day 12 (3.95) 9 (2.96) 19 (6.25) 7 (2.30) 47 (15.46)
Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100) Teeth cleaned by:
Mother/father/guardian 14 (4.61) 22 (7.24) 54 (17.76) 47 (15.46) 137 (45.07)
0.004 Child brushes his/her
own teeth 37(11.18) 33 (10.86) 46 (15.13) 43 (14.14) 159 (52.30) Do not know 4 (1.32) 2 (0.65) 2 (0.65) 0 (0.00) 8 (2.63) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
Duration of tooth brushing
≥2 minutes 24 (7.89) 16 (5.26) 55 (18.09) 28 (9.21) 123 (40.46)
<0.001 <2 minutes 23 (7.57) 36 (11.84) 37 (12.17) 54 (17.76) 150 (49.34)
Do not know 8 (2.63) 5 (1.64) 10 (3.29) 8 (2.63) 31 (10.20) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
Is any of the auxiliary methods used to clean child’s teeth/gums? Dental floss 4 (1.32) 6 (1.97) 11 (3.62) 12 (3.95) 33 (10.89)
0.019 Mouthwash 9 (2.96) 9 (2.96) 20 (6.58) 16 (5.26) 54 (17.76)
Dental floss &
mouthwash 1 (0.33) 0 (0.00) 3 (0.99) 3 (0.99) 7 (2.30) Chew stick/miswak 2 (0.66) 10 (3.29) 1 (0.33) 4 (1.32) 17 (5.59) Not used 39(12.83) 32 (10.53) 67 (22.04) 55 (18.09) 193 (63.49) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
Type of toothpaste used
With fluoride 29 (9.54) 29 (9.54) 70 (23.03) 75 (24.67) 203 (66.78)
<0.001 Fluoride-free 15 (4.93) 21 (6.91) 22 (7.24) 11 (3.62) 69 (22.70)
Do not know 11 (3.61) 7 (2.30) 10 (3.29) 4 (1.32) 32 (10.53) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
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all parents reported that the reason was toothache. The differences among parents with different education levels are statistically significant (p<0.001).
Table 3. Relationship between parental education level, history of child’s experienced toothache and dental visits.
35.5% of children consume fresh fruit meanwhile 36.20 % consume jam/honey at least once a day. Additionally, 70.40% of the children drink milk/hot drink with sugar least once a day. The results also show occasional consumption of biscuit/cake/pastry (36.30%), soft drink (39.20%), sweets (37.20%) and sugar-containing chewing gum (38.20) by children. On the other hand, 18.40% of the children never consumed biscuits/cake/pastry and 17.40% of children never consumed chewing gum containing sugar. Moreover, 37.20% of children never drank milk/hot drinks with sugar and 14.80% did not consume sweets. There was only one statistically significant difference found in the dietary habit part. Significantly more parents with secondary school education answered that their children eat fresh fruits daily (p=0.028) (Table 4). Variable Parental education N (%) Total N (%) P-value No formal education Primary school completed Secondary school completed College/ university completed Frequency N (%) Frequency of toothache/discomfort experienced by child in the past 12 months Often 5 (1.64) 8 (2.63) 22 (7.24) 12 (3.95) 47 (15.46) 0.001 Occasionally 30 (9.87) 29 (9.54) 50 (16.45) 52 (17.11) 161 (52.96) Never 8 (2.63) 12 (3.95) 25 (8.22) 22 (7.24) 67 (22.04) Do not know 12 (3.95) 8 (2.63) 5 (1.64) 4 (1.32) 29 (9.54) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
Frequency of child’s dental visits in the past 12 months
≥Twice 14 (4.61) 23 (7.57) 50 (16.45) 58 (19.08) 145 (47.70)
<0.001 Once 20 (6.58) 13 (4.28) 38 (12.50) 20 (6.58) 91 (29.93)
>12 months ago 16 (5.26) 12 (3.95) 12 (3.95) 8 (2.63) 48 (15.79) Never visited a dentist 5 (1.64) 9 (2.96) 2 (0.66) 4 (1.32) 20 (6.59) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
Reason for child’s last dental visit in the past 12 months
Toothache 13 (4.28) 15 (4.93) 22 (7.24) 13 (4.28) 63 (20.72)
<0.001 Dental treatment 10 (3.29) 9 (2.96) 36 (11.84) 25 (8.22) 80 (26.32)
Routine check-up 12 (3.95) 12 (3.95) 31 (10.20) 39 (12.83) 94 (30.92) Did not visit 20 (6.58) 21 (6.91) 13 (4.28) 13 (4.28) 67 (22.04) Total 55(18.09) 57 (18.75) 102(33.55) 90 (29.61) 304 (100)
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Table 4. Dietary habits of children.
Question Once a day ≥
N(%) Several times a week N(%) Occasionally N(%) Never N(%)
Frequency of fresh fruit
consumption 109(35.90) 57(18.80) 99(32.50) 39(12.80) Frequency of biscuit/cake/pastry consumption 88(28.90) 50(16.40) 110(36.30) 56(18.40) Frequency of coke/soft drink consumption 91(29.90) 53(17.40) 119(39.20) 41(13.50) Frequency of jam/honey consumption 110(36.20) 60(19.70) 94(30.90) 40(13.20)
Frequency of chewing gum
containing sugar 91(29.90) 44(14.50) 116(38.20) 53(17.40)
Frequency of sweets/candy
consumption 104(34.20) 42(13.80) 113(37.20) 45(14.80)
Frequency of drinking
milk with sugar 106(34.90) 53(17.30) 88(29.00) 57(18.80)
Frequency of drinking tea/coffee/hot drink with
sugar
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DISCUSSION
Numerous studies have been carried out to compare the association between parental education level and caries prevalence in children, however, only a few studies can be found which compare the relationship between parental education level and specific oral hygiene habits of children. Therefore, the main focus of this study is on the comparison of parental education level with oral hygiene habits of their children. The results attained in this study will be compared with results from existing studies. According to The European Academy of Paediatric Dentistry, parents should ensure their children’s teeth are brushed just before bedtime and on no less than one more occasion during the same day [21]. This study shows that the recommended frequency of tooth brushing is followed as 84.54% of the children brush their teeth at least twice daily whereas 15.46% only brush their teeth once a day. The majority of children who brushed their teeth at least twice a day had parents with a higher level of education; 27.30% had completed university/college and another 27.30% had completed
secondary/high school.
Similarly, a recent study in Amsterdam found that 83.4% of children brushed their teeth at least twice a day meanwhile only 16.6% brushed their teeth once a day with the majority of parents having “higher” education level (38.5%), closely followed by 36.2% of parents with “medium” education level [22]. The findings of various other studies support the results of this current study [24-26].
Additionally, it is highly recommended for parents to assist/supervise tooth brushing [27, 28] until the child is no less than 7 years of age [21] as young children lack the hand coordination required to brush their teeth independently prior to that age [29]. In this study, 45.07% of parents brushed their child’s teeth while 52.30% of the parents allowed children to brush their own teeth. The majority of parents who brushed their child’s teeth had completed secondary school or university (33.22%), however, these were also the most prevalent groups in regards to the parents of children who brushed their own teeth (29.27%). On the contrary, a study conducted in United Arab Emirates found that 57.4% of the parents brush their child’s teeth while 36.4% let their children brush their own teeth with the majority of parents having a high school education [25].
The recommended duration of tooth brushing should be more than one minute each time [21]. In this study, the most prevalent duration of tooth brushing was up to two minutes (49.34%) followed by 40.46% who spent at least two minutes on tooth brushing. More children who spent at least two minutes on tooth brushing had parents who only completed secondary school than university (18.09% vs. 9.21%). Berendsen et al. found similar results as 33.2% of parents with “medium” education level
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had children who spent more than 2 minutes on tooth brushing in comparison with parents of “higher” education level (26.1%) [22].
Early use of fluoridated toothpaste for tooth brushing is recommended as, evidently, fluoride has been used for the prevention of caries for decades and is considered the main reason for the reduction of dental caries [21, 27]. In the current study, a greater number of parents (66.78%) used fluoridated toothpaste to clean their child’s teeth. Among those parents, 24.67% were university graduates followed by 23.03% who had completed secondary school. Only 9.54% equally in both parents with primary school education and those of no formal education used fluoridated toothpaste proposing that parents with a higher education level had an increased awareness in regards to the oral health of children. In agreement with our findings, the results of the study conducted by Prabhu et al. suggested that less than half of the parents reported using fluoridated toothpaste (42.67%) with the majority of participants being less educated parents [30].
In the present study, 22.04% of children had never experienced toothache in the previous 12 months. Only 2.63% of these children had parents with no formal education while 8.22% had parents who only completed secondary school and another 7.24% had parents with a college/university degree indicating that more children who never experienced toothache in the last 12 months had well-educated parents. These results are in agreement with results obtained from several other studies which compared parental education level with child toothache frequency [24, 31, 32].
It is advised that the paediatric dentist should have routine dental examinations 1-2 times a year to examine the child’s dental development and detect possible caries development [33]. Irregular dental visits are very common as parents do not ensure regular dental care for their children in their early years of life [34]. Comparable to this study which shows a great difference between the percentage of university educated parents who took their children to the dentist at least twice in the last 12 months and non-educated parents (19.08% vs. 4.61%), a few recent studies achieved similar findings [22, 35]. Additionally, a study conducted in the USA found that more parents who completed high school visited the dentist with their child once yearly than parents who hadn’t completed high school (76.3% vs. 69.7%) [24] which is in agreement with this current study which shows that 19.08% of children with parents who completed high school visited the dentist once in the past 12 months in comparison to 10.86% of children with parents who hadn’t completed high school.
Moreover, the American academy of paediatric dentistry states that the main factor to seeking dental care is toothache [34], however, in this study, routine dental examinations was the main factor for visiting the dentist (30.92%) with university educated parents occupying 12.83% compared to parents of no formal education who occupied 3.95% which implies that well educated parents have a more
22
positive attitude toward oral hygiene. On the other hand, as a reason for dental visit in the last 12 months, toothache occupied 4.28% equally in both university educated parents and non-educated parents. Heima et al. found that a higher percentage (92.9%) of well-educated parents ensured routine dental examinations for their children in comparison to low educated parents (87.1%) which supports the findings of this current study [24].
Certainly, sugar consumption is associated with the development of caries in children [36-38].
Research has shown that the frequency of sugar consumption has a greater effect on the development of caries than the total sugar intake [39]. A study conducted in Saudi Arabia assess the frequency of children’s consumption of cariogenic foods and found that children consumed carbonated drinks (40.6%), cake (15.8%) an sweets (14.5%) on a daily basis if not several times a day [40].
Correspondingly, the findings of the present study suggest a great frequency of sugar consumption by children although the frequency of consumed sweets and cake is higher in our study; 29.9% consumed soft drinks, 28.9% consumed biscuits/cake/pastries and 34.2% consumed sweets a least once daily, however, there was no statistically significant difference between parental education level and the frequency of consumption of these sweetened products.
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CONCLUSION
The attitude and awareness of parents/guardians regarding the children oral health is insufficient. Reported oral hygiene behaviour was more favourable in children whose parents had a higher
education level (secondary and university). Two thirds of parents use fluoridated toothpaste and parents with university education prevailed. Majority of parents did not use any other auxiliary method to clean their child’s teeth, especially those with no formal education. A high prevalence of children consumed sweetened products and sweetened beverages daily, however, parental education did not play a role in the dietary habits of children.
ACKNOWLEDGEMENT
I would like to express my sincere gratitude and appreciation to my thesis supervisor Dr, Sandra Žemgulytė of the Faculty of Odontology at the Lithuanian University of Health Sciences for the valuable guidance, continuous support, and immense knowledge. My sincere thanks also goes to the principal of Ikhlass School who allowed me to conduct this research at her facility.
PRACTICAL RECOMMENDATIONS
When planning dental services for children, information on parental behaviour and attitude toward children’s oral health should be taken into consideration. Lectures for parents and children should be organised in order to emphasize the importance of oral health, oral hygiene and dietary habits. Leaflets can be prepared with useful information as well. Since children already attend school, teachers or school staff could give short lectures about maintaining a healthy life style for children.
CONFLICT OF INTEREST
The author, Nor Hassan Sadek, has not encountered any conflict of interests.24
REFERENCES
1. World Health Organization. Oral health. 2012; Available at:http://www.who.int/oral_health/publications/factsheet/en/. Accessed October 12, 2017. 2. Alm A, Wendt LK, Koch G, Birkhed D, Nilsson M. Caries in adolescence – influence from
early childhood. Community Dent Oral Epidemiol 2012;40(2):125-133.
3. Daly JM, Levy SM, Xu Y, Jackson RD, Eckert GJ, Levy BT, et al. Factors Associated With Parents’ Perceptions of Their Infants’ Oral Health Care. Journal of Primary Care & Community Health 2016;7(3):180-187.
4. Health and Social Care Information Centre. Children’s Dental Health Survey. 2015; Available at: https://digital.nhs.uk/data-and-information/publications/statistical/children-s-dental-health-survey/child-dental-health-survey-2013-england-wales-and-northern-ireland. Accessed October 12, 2017.
5. Drummond B, Meldrum A, Boyd D. Influence of dental care on children's oral health and wellbeing. Br Dent J 2013;214(11):E27.
6. Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M. Prevention of Dental Caries in Children Younger Than 5 Years Old: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Agency for Healthcare Research and Quality 2014 May.
7. Simons D. A pilot of a school- based dental treatment programme for vulnerable children with possible dental neglect: the Back2School programme. Br Dent J 2013;215(8):E15.
8. Acharya S, Pentapati K, Bhat P. Dental neglect and adverse birth outcomes: a validation and observational study. International Journal of Dental Hygiene 2013;11(2):91-98.
9. Gurunathan D, Shanmugaavel AK. Dental neglect among children in Chennai. J Indian Soc Pedod Prev Dent 2016 Oct-Dec;34(4):364-369.
10. Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the
development of dental caries in children aged 0– 6 years: A systematic review of the literature. J Dent 2012;40(11):873-885.
11. Kumar S, Kroon J, Lalloo R. A systematic review of the impact of parental socio- economic status and home environment characteristics on children's oral health related quality of life. Health and quality of life outcomes 2014;12:41.
12. Kenney MK, Kogan MD, Crall JJ. Parental Perceptions of Dental/ Oral Health Among Children With and Without Special Health Care Needs. Ambulatory Pediatrics 2008;8(5):312-320.
25
13. Sohn W. Caregiver's perception of child's oral health status among low- income African Americans. Pediatr Dent 2008;30(6):480.
14. Nadazdyova A, Sirotnakova D, Samohyl M. Parents' Dental Knowledge and Oral Hygiene Habits in Slovak Children. Iranian journal of public health 2017;46(7):999.
15. ElKarmi R, Shore E, O’Connell A. Knowledge and behaviour of parents in relation to the oral and dental health of children aged 4– 6 years. Eur Arch Paediatr Dent 2015;16(2):199-204. 16. Lourenço CB, Saintrain MVdL, Vieira APGF. Child, neglect and oral health. BMC pediatrics
2013;13(1):188.
17. Wigen TI, Skaret E, Wang NJ. Dental avoidance behaviour in parent and child as risk indicators for caries in 5‐ year‐ old children. International Journal of Paediatric Dentistry 2009;19(6):431-437.
18. Saldūnaitė K, Bendoraitienė E, Slabšinskienė E, Vasiliauskienė I, Andruškevičienė V, Zūbienė J. The Role of parental education and socioeconomic status in dental caries prevention among Lithuanian children. Medicina 2014;50(3):156-161.
19. Jacobsson B, Ho Thi T, Hoang Ngoc C, Hugoson A. Sociodemographic conditions, knowledge of dental diseases, dental care, and dietary habits. J Public Health Dent 2015;75(4):308-316. 20. Office for National Statistics. London and UK population. 2016; Available at:
https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/londona ndukpopulation. Accessed October 20, 2017.
21. Guidelines on the use of fluoride in children: an EAPD policy document. Eur Arch Paediatr Dent 2009;10(3):129-135.
22. Berendsen J, Bonifacio C, Van Gemert‐Schriks M, Van Loveren C, Verrips E, Duijster D. Parents’ willingness to invest in their children's oral health. J Public Health Dent
2018;78(1):69-77.
23. Peres MA, Nascimento GG, Peres KG, Demarco FF, Menezes AB. Oral health‐ related
behaviours do not mediate the effect of maternal education on adolescents' gingival bleeding: A birth cohort study. Community Dent Oral Epidemiol 2018;46(2):169-177.
24. Heima M, Lee W, Milgrom P, Nelson S. Caregiver's education level and child's dental caries in African Americans: a path analytic study. Caries Res 2015;49(2):177-183.
25. Hashim R, Williams S, Thomson WM. Oral hygiene and dental caries in 5- to 6- year- old children in Ajman, United Arab Emirates. International journal of dental hygiene
26
26. Zhou Y, Lin HC, Lo ECM, Wong MCM. Risk indicators for early childhood caries in 2- year- old children in southern China. Aust Dent J 2011;56(1):33.
27. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent 2013 Sep-Oct;35(5):E165-8.
28. Wong MCM, Glenny A, Tsang BW, Lo ECM, Worthington HV, Marinho VC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Oral Health Group 2010;6(1).
29. American Academy of Pediatrics. A Pediatric Guide to Children’s Oral Health. 2009; Available at:
https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Documents/OralHealthFCpagesF2_2_1.pdf. Accessed February 16, 2018. 30. Prabhu A, Rao AP, Reddy V, Ahamed SS, Muhammad S, Thayumanavan S. Parental
knowledge of pre- school child oral health. J Community Health 2013;38(5):880.
31. Escoffié-Ramirez M, Ávila-Burgos L, Baena-Santillan E, Aguilar-Ayala F, Lara-Carrillo E, Minaya-Sánchez M, et al. Factors Associated with Dental Pain in Mexican Schoolchildren Aged 6 to 12 Years. BioMed research international 2017;2017:7431301.
32. Kumar Y, Acharya S, Pentapati K. Prevalence of dental pain and its relationship to caries experience in school children of Udupi district. Eur Arch Paediatr Dent 2014;15(6):371-375. 33. European Academy of Paediatric Dentistry. THE FIRST DENTAL PROBLEMS OF THE
INFANTS. Available at: https://www.eapd.eu/index.php/post/the-first-dental-problems-of-the-infants. Accessed February 24, 2018.
34. American Academy of Pediatric Dentistry. Policy on the Dental Home. Pediatr Dent 2012;34(6):24-26.
35. Ji Y. Association between family factors and children's oral health behaviors--a cross- sectional comparative study of permanent resident and migrant children in large cities in China.
Community Dent Oral Epidemiol 2016;44(1):92.
36. Wigen TI, Wang NJ. Does early establishment of favorable oral health behavior influence caries experience at age 5 years? Acta Odontologica Scandinavica, 2014, 2014;73; Vol.73(3; 3):182; 182-187; 187.
37. Meurman PK, Pienihakkinen K. Factors associated with caries increment: a longitudinal study from 18 months to 5 years of age. Caries Res 2010;44(6):519-524.
38. Masson LF, Blackburn A, Sheehy C, Craig LCA, Macdiarmid JI, Holmes BA, et al. Sugar intake and dental decay: results from a national survey of children in Scotland. Br J Nutr 2010;104(10):1555-1564.
27
39. Anderson CA, Curzon MEJ, Van Loveren C, Tatsi C, Duggal MS. Sucrose and dental caries: a review of the evidence. Obesity Reviews 2009;10:41-54.
40. Amin T, Al‐Abad B. Oral hygiene practices, dental knowledge, dietary habits and their relation to caries among male primary school children in Al Hassa, Saudi Arabia. International Journal of Dental Hygiene 2008;6(4):361-370.
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ANNEXES
Annex No. 1
Questionnaire for parents
Parental perception of children’s oral health at a Middle Eastern school in west London
I am NOR HASSAN SADEK, the dental student of Lithuanian University of Health Sciences and I am conducting a scientific research, which is aimed to evaluate the attitude and awareness of children’s oral health among Middle Eastern parents with children attending a Saturday school in west London. The research participants are parents of children attending Ikhlass School in west London.
The research data collected from the anonymous questionnaires will only be used for scientific purposes and confidentiality is guaranteed.
If you require any further information, feel free to contact Nor Hassan Sadek: LSMU, MA. Clinic for Preventive and Paediatric Dentistry
Adress: J. Lukšos-Daumanto g. 6, LT-50106, Kaunas, Lithuania Tel no: +370 (641) 77 988,
E-mail: Sadek.nor@gmail.com
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CONSENT FORM FOR RESEARCH PARTICIPANT
I,………..., understand all information provided to me in the information sheet and agree to participate in the research of Nor Hassan Sadek “Parental perception of children’s oral health at a Middle Eastern school in west London” aimed to evaluate the attitude and awareness of children’s oral health among Middle Eastern parents with children attending a Saturday school in west London.
Name, surname of research participant _____________________
(Signature)
No._______________ Date ____________
1. Who is answering the questions in this questionnaire?
• Mother • Father • Guardian
2. What is your age?
3. What is your completed education level?
• No formal education • Primary school completed
• Secondary/high school completed • College/university completed
4. What is the gender of your child?
• Female • Male
5. What is the age of your child?
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7. How often during the past 12 months did your child have toothache or feel discomfort due to his/her teeth?
• Often • Occasionally
• Rarely • Never • I don’t know
8. How often did your child visit the dentist during the past 12 months?
• Once • Twice • Three or more times
• My child did not visit the dentist during the past 12 months
• My child has never visited a dentist
• I don’t know
If your child did not visit the dentist during the past 12 months, please go to question 10 9. What was the reason for your child’s last visit to the dentist during the past 12 months?
• Toothache • Dental treatment • Routine check-up
10. How often is your child’s teeth cleaned?
• Never • Occasionally
• Several times a week (2-6 times) • Once a day • Twice or more times a day
If your child’s teeth are never cleaned, please go to question 16 11. Who usually cleans your child’s teeth?
• Mother/Father/Guardian • My child brushes his/her own teeth
• I don’t know
12. Approximately how long is the procedure of cleaning your child’s teeth?
• Less than 1 minute • 1-2 minutes
• 2-3 minutes • I don’t know
13. Is any of the auxiliary measures used to clean your child’s teeth or gums?
• Dental floss • Mouthwash
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14. Is toothpaste used to clean your child’s teeth?
• Yes • No • I don’t know
If toothpaste is not used to clean your child’s teeth (or the answer is “I don’t know”), please go to question 16.
15. If the answer to question 14 is “Yes”, does the toothpaste used contain fluoride?
• Yes • No • I don’t know
16. How often does your child eat any of the following foods (even in small quantities)?
Several times a day
Every day Several times a week
Once a week Occasionally Never
Fresh fruit Biscuits, cakes, pastries etc. Coke or any other soft drinks Jam/honey Chewing gum containing sugar Sweets/candy Milk with sugar Tea/coffee or any other hot drink with sugar
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Annex No. 2
Ethical approval
33
EVALUATION FORM OF THE MASTER’S THESIS FOR THE MEMBER OF DEFENCE COMMITTEE
Graduate student________________________________________________________________, of the year ______, and the group _____ of the integrated study programme of Odontology
Master’s Thesis title:
………...……….………...……… ………...….………...……...
No. MT evaluation aspects Evaluation
Yes Partially No 1 Has the student’s presentation lasted for more than 10 minutes?
2 Has the student presented the main problem of the Master’s thesis, its aim and tasks?
3 Has the student provided information on research methodology and main research instruments?
4 Has the student presented the received results comprehensively? 5 Have the visual aids been informative and easy to understand? 6 Has the logical sequence of report been observed?
7 Have the conclusions been presented? Are they resulting from the results?
8 Have the practical recommendations been presented?
9 Have the questions of the reviewer and commission’s members been answered correctly and thoroughly?
10 Is the Master’s thesis in compliance with the essence of the selected study programme?
Remarks of the member of evaluation committee of Master’s Thesis
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________________________
Evaluation of the Master’s Thesis
_____________________________________________________________________________
Member of the MT evaluation committee:
________________ ___________________________ _____________________
