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Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 186-191

Association of maternal oral health-related knowledge, attitude, and socioeconomic status with dental caries status of preschoolchildren in Belgaum City: A cross-sectional study

1 Oral Health Sciences Centre, PGIMER, Chandigarh, India
2 Department of Public Health Dentistry, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India
3 Private Dental Practitioner (Pedodontist), Chandigarh, India
4 Department of Public Health Dentistry, DY Patil Dental College, Pune, Maharashtra, India

Date of Submission09-Jan-2019
Date of Acceptance08-Aug-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Dr. Nishant Mehta
Oral Health Sciences Centre, PGIMER, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_227_18

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Background: Oral health status is dependent on the interplay of multiple etiological and predisposing factors, which have varying ability to cause diseases. However, little is known about maternal factors associated with the oral health of preschoolchildren at different stages of their development. Aim: To assess the association of maternal oral health-related knowledge and attitude with the preschoolchildren's dental caries status. Materials and Methods: The present study was a cross-sectional study conducted among 618 mother–child pairs. Three to 5-year-old preschoolchildren were selected from eight preprimary schools following two-stage random sampling. Responses from the mothers on oral health-related knowledge and attitude were collected through a structured questionnaire. It was followed by dental caries examination of their preschoolchildren based on the WHO criteria for dental caries examination. Chi-square test was done to find the association between the study variables. Model for the prediction of dental caries occurrence in preschoolchildren was generated following multiple logistic regression analysis. Level of significance was set at P < 0.05. Results: The mean correct oral health-related knowledge and attitude scores of mothers were 6.59 ± 2.35 and 7.28 ± 1.83, respectively. Preschoolchildren had a mean untreated dental caries score of 2.73 ± 1.63 and decayed, missing, and filled teeth score of 3.13 ± 1.79. Untreated dental caries in children was found to be statistically significantly associated with maternal oral health-related knowledge ( P = 0.021) and attitude ( P = 0.006). Mothers who were having better knowledge and favorable attitude toward oral health had significantly lower odds of developing dental caries in their children as reflected by the logistic regression analysis (odds ratio = 0.33 [0.22–0.52] and 0.36 [0.24–0.53], respectively). Conclusion: The study concluded that maternal factors were significantly related to children's dental caries status and emphasized the need of raising awareness among mothers for limiting and controlling dental caries among preschoolchildren.

Keywords: Attitude, child, dental caries, knowledge, preschoolchildren

How to cite this article:
Mehta N, Ankola A, Chawla N, Rajpurohit L. Association of maternal oral health-related knowledge, attitude, and socioeconomic status with dental caries status of preschoolchildren in Belgaum City: A cross-sectional study. J Indian Assoc Public Health Dent 2019;17:186-91

How to cite this URL:
Mehta N, Ankola A, Chawla N, Rajpurohit L. Association of maternal oral health-related knowledge, attitude, and socioeconomic status with dental caries status of preschoolchildren in Belgaum City: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2022 Aug 8];17:186-91. Available from: https://www.jiaphd.org/text.asp?2019/17/3/186/266762

  Introduction Top

Oral diseases are common in many societies worldwide, with dental caries being the most prevalent affecting all age groups.[1] Dental caries is a multifactorial, bacteriologically mediated chronic disease which is present around the globe in low-income, middle-income, and high-income countries and affects 60%–90% of children in industrialized nations.[2],[3] It can cause a child to suffer a significant degree of pain, and if left untreated, the disease may lead to further complications including sepsis.[4],[5] Severe untreated caries has also been found to have links to general health and well-being, affecting young children's body weight and growth and smooth progression to adulthood.[6] Children suffer from many infectious diseases during the first few years of life and despite improvement in the general health status over several decades, oral diseases still stay a serious problem.[7] Oral health status is dependent on the interplay of multiple etiological and predisposing factors with varying abilities. Previous studies point to the integral role of biological, behavioral, socioeconomical, and psychological variables in the caries experience of children.[8],[9] If a child is relatively free from dental caries in the primary dentition, the permanent dentition might also experience limited or less number of lesions.[10] Children have been shown to adopt individual lifestyle, dietary patterns, and feeding preferences from their mothers during their early childhood.[11] Mothers are the primary role model for developing and shaping oral health behaviors in their children during early years of life. Children more often share similar oral bacterial strains with their mothers than with any other family members, and children of mothers who are highly infected with Mutans streptococci usually show high infection levels and vice versa. Early establishment of Mutans streptococci in young children is predictive of early and extensive development of caries in the primary dentition.[1],[7] Therefore, it becomes imperative for a mother to be well aware regarding the importance of healthy oral health practices in children. However, previous studies have cited the need to carry out detailed assessment of maternal awareness and attitude taking into consideration the socioeconomic class to which the mothers belong so as to effectively target mothers.[10],[11] This study shall become the basis for the formulation of a target plan for dental caries in preschoolchildren that will be upon the felt needs of mothers rather than just being a normative one. In addition, objective assessment of role played by maternal factors in the development of dental caries in preschoolchildren shall be explored upon. Hence, the present study was planned to determine and assess the influence of maternal-related factors (oral health-related knowledge, attitude, and sociodemographics) on the dental caries status of the child.

  Materials and Methods Top

Study design and study setting

The present study was an analytical cross-sectional study conducted among 618 preschoolchildren and their mothers to assess the association between maternal oral health-related knowledge, attitude, and sociodemographic status and the children's dental caries status. Ethical approval was obtained from the Institutional Ethics Committee (vide no. IL0211002/580), and necessary permissions were also obtained from concerned authorities such as Child Development Office, Belgaum, and headmasters and principals of the respective preschools. A schematic representation of the methodology is depicted in [Figure 1].
Figure 1: Schematic representation of the study methodology

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Sample size estimation

Sample size was calculated utilizing the data on the prevalence (60%) of dental caries as obtained from a pilot study conducted among fifty preschoolchildren based on the following formula: 4 × prevalence × (1 − prevalence)/(admissible error)2 × design effect.[12] Admissible error and design effect were kept at 4% and 1.5, respectively. The desired sample size turned out to be 576 and to compensate for any loss of participants during data collection, an additional 10% of sample was added to this. The final study sample consisted of a total of 618 children.

Sampling methodology

Stratified random sampling was used to recruit the study participants. A list of schools in Belgaum was obtained from the Child Development Office. Accordingly, there were a total of 244 preschools in Belgaum city. In the first stage, Belgaum city was divided into Belgaum North and Belgaum South. Four schools from each zone were selected using a table of random numbers to achieve the desired sample size. From each school, 70–80 children were randomly selected using computer-generated sequencing.

Details and pretesting of the questionnaire

A self-structured close-ended questionnaire was used to record the knowledge and attitude of mothers regarding the oral health of their children. It consisted of two parts: the first part included questions pertaining to sociodemographic details, whereas the second part had 12 questions each on the knowledge and attitude of mothers about the oral health of their preschoolchildren. Kuppuswamy scale was used to record the socioeconomic status (SES) of mothers.[13] The questionnaire was reviewed by experts (who were active in the field of maternal and child oral health), and content validity was ensured. The questionnaire was translated into regional language by an expert, and back translation was done to establish linguistic validity. A pilot study was conducted to determine the test–retest reliability of the survey questions in the present scenario (Cronbach's alpha = 0.82); fifty mothers who completed the survey during the initial administration completed the survey 2 weeks later. The respondents were also asked for feedback on clarity of the questions and whether there was any difficulty in answering the questions or ambiguity as to what sort of answer was required. The participants who participated in the pilot study were not included in the final sample.

Data collection

Selected 3- to 5-year-old children from eight schools and their mothers were invited to participate in the study. Mothers and children who were staying in Belgaum city, at least since the last 3 years, were eligible to take part in the study. Mother–child pair was excluded from the study if the child was medically compromised. Written informed consent was obtained from the mothers prior to the start of the study. The schools were visited on the scheduled dates, and the mothers' oral health-related knowledge and attitude were assessed by the investigator using a close-ended questionnaire. The mothers were briefed regarding the questionnaire and were requested not to leave any questions blank. After the questionnaires were collected back, children's decayed, missing, and filled teeth (dmft) status based on the WHO criteria was recorded to assess their oral health status.[14] Type III clinical examination was performed under natural lighting conditions by a single trained and calibrated investigator in the school premises. Not more than thirty mother–child pairs were assessed per day.[15]

Following data collection for the study, an interactive oral health education camp was conducted for the mothers which enabled them to clarify their queries regarding feeding practices, oral hygiene measures, time of visiting a dentist, etc. They were also referred to the nearest dental facility for any oral diseases encountered in their children during the oral health examination.

Details of statistical analysis

Data were entered in Microsoft Excel and analyzed using SPSS Statistics software, version 17 (IBM, Chicago IL, USA). Variables were expressed as frequencies and mean ± standard deviation, as required. To generate cutoff values in the knowledge and attitude questionnaire, all correct responses were scored as +1; wrong answers as −1; and those answered as do not know were scored 0. Correct answer score for all the mothers was calculated based on the total number of correct responses. Based on the 33rd and 66th percentiles of the total correct answer score, the mothers' knowledge and attitude were categorized into good, fair, and poor. Those who scored ≤33rd percentile were grouped into “poor” knowledge and attitude category, those who scored >33rd ≤66th percentile were grouped into “fair” knowledge and attitude category, and those who scored >66th percentile were grouped into “good” knowledge and attitude category related to oral health. Further, the frequency of good and fair responses was clubbed for binary logistic regression. For ease of statistical analysis, upper, upper-middle, upper-lower, and lower categories were clubbed. Chi-square test was done to know the association between the study variables. Binary logistic regression analysis was carried out to generate a model for the prediction of dental caries among preschoolchildren. Level of significance was set at P < 0.05.

  Results Top

A total of 618 preschoolchildren in the age range of 3–5 years and their mothers participated in the study. As per the Kuppuswamy Scale for SES classification, 13.8% of the participants belonged to upper and upper-middle strata, 15.7% fell into lower-middle strata, and majority, i.e., 70.5% were from upper-lower and lower strata. The number of male children was higher than the female children (55.7% vs. 44.3%). Representation from ages 3, 4, and 5 was 30%, 35%, and 35%, respectively [Table 1]. The mean number of untreated dental caries, missing teeth due to caries, and filled teeth in children was 2.73 ± 1.63, 1.69 ± 0.90, and 1.94 ± 0.77, respectively, with a mean dmft count of 3.13 ± 1.79 [Table 2]. Nearly 54.7% of the mothers were aware of the importance of good oral health for overall health, 32.7% of the mothers considered primary teeth as important as permanent teeth [Table 3], 21.4% of the mothers did not know that frequent consumption of sugar can cause tooth decay, and 60.2% of the mothers felt that dentist should be visited only during toothache [Table 4]. Overall 205 and 235 mothers had fair-to-good knowledge and attitude. Maternal oral health-related knowledge and attitude were statistically significantly associated with the presence of dental caries in their children ( P < 0.05). Nearly 52.9% of the children had the presence of one or more teeth with dental caries [Table 5]. Going from lower to upper SES and poor to good/fair knowledge and attitude of mothers, the likeliness of getting dental caries in children decreased significantly. There were 68% (odds ratio [OR] =0.32), 67% (OR = 0.33), and 64% (OR = 0.36) lesser chances of getting dental caries among children who belonged to upper SES and whose mothers had good oral health-related knowledge and attitude, respectively [Table 6].
Table 1: Distribution of children according to age and gender

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Table 2: Mean and standard deviation of different maternal and child variables

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Table 3: Knowledge scores of mothers based on the total number of correct answers

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Table 4: Attitude scores of mothers

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Table 5: Association of dental caries in children with different maternal variables

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Table 6: Relationship of dental caries of children with different study variables using logistic regression analysis

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  Discussion Top

Oral health of preschoolchildren is an overlooked aspect of childhood health and well-being. In the present study, the prevalence of dental caries among preschoolchildren was found to be 52.7%, which is comparable to the finding from other studies. The National Oral Health Survey of India also reported a high prevalence of caries in primary dentition of 5-year-old children in India, with 51.9% of the children in this age group being affected with caries.[16],[17] Earlier studies showed that a large proportion of children who were free of the oral diseases in the primary dentition remained so in the permanent dentition, whereas children with poor oral health in the early ages of life were more likely to have oral health problems later in their life.[18] Early infection of the permanent dentition by microorganisms may have been due to their presence in plaque or other carious lesions.[19] In this study, the mean number of dental caries among children was found to be 2.73 ± 1.63, which is comparable to other studies.[20],[21] These high levels of untreated dental caries among the study participants can be due to its multifactorial nature, where numerous risk factors such as frequent snacking, milk consumption with sugar before going to bed, improper brushing, and oral hygiene habits contribute in the development of dental caries. It is generally agreed that mothers act as role model in shaping the oral health behavior of young children. Maternal attitude is likely to modify behavior and thus plays an important part in the uptake of favorable dental health practices. Maternal low education level, age, rural domicile, infrequent tooth cleaning, the presence of plaque on children's teeth, and frequent sugar consumption by the children have been associated with poor oral health of the children.[22],[23],[24] Furthermore, studies have also depicted the association between the types of bacterial strains among mothers and children, with children found to have similar bacterial strains as their mother had in their mouth; also, the intensity of infection among the children and mothers was found to be similar.[25] Although dental care providers perceive this correlation between the maternal factors and oral health of children intuitively, limited information exists to support this relationship.[26] However, there is very little evidence to effectively quantify the expected association between oral health-related knowledge and attitude of mothers and that of their children. The present study was conducted using untreated dental caries of children as a measure of children's oral health status which is influenced mostly by maternal factors. In this study, it was seen that the higher SES of the mothers presented with lower number of untreated caries in children ( P < 0.001, OR = 0.321), which is in line with other studies which assessed the similar kind of association.[20],[27],[28] Maternal oral health-related knowledge and attitude were assessed on the basis of correct answers provided. The mean correct knowledge and attitude scores were 6.59 ± 2.35 and 7.28 ± 1.83, respectively. Majority of the mothers were found to have good-to-fair knowledge and attitude scores (76% and 71.35%, respectively), which is in corroboration with the studies done by Haloi et al., Mani et al., and Saied-Moallemi et al., but mothers' knowledge was found to be inadequate when they were asked particularly about the significance of milk teeth, role of bacteria in the causation of dental caries, correct timing of visit to dentist, and the role of fluorides, which is comparable to a study done by Chhabra and Chhabra.[20],[28],[29],[30] For change of mothers' knowledge and attitudes from poor to good/fair, the odds of caries decreases by 54% and 62%, respectively (OR = 0.34 and 0.46, respectively, P < 0.05). These findings are supported by the studies done by Haloi et al. in Mathura, India, Okada et al. in Japan, and Adeniyi et al. in the USA.[10],[20],[21] In another study, Saied-Moallemi et al. got the similar results for attitude but nonsignificant odds ratios for mothers' knowledge; the possible reason we believe for this mismatch could be the strong holding of mothers' knowledge on their attitudes, subsequently both affecting the untreated dental caries of their children.[1],[30] However, the association of mothers' behaviors and children's oral health is not a straightforward cause-to-effect relationship. Knowledge is the predecessor of healthy attitudes which act as a tool for the implementation of sound practices among the young children which are carried out throughout their life.[31],[32] In addition, from the perspective of family, children should not be regarded as just the inert receptors of care; instead, they should be promoted to carry out healthy lifestyles.[33] This meaningful impression of mothers' attitude on their children's dental health can be influenced by their attitudes on parental caring conducts for their little ones.[34],[35] Further, it refers to extensive interactions between mothers and their children, which further promote their role as teachers for shaping their children's perceptions, beliefs, attitudes, behaviors, and practices.[36] These findings support the need for the development of adequate oral health knowledge and attitude among mothers for oral health promotion of their children. However, limitations of any cross-sectional study emphasize the need to undertake a cautious interpretation of results, with cross-sectional studies being at the lower end of evidence to establish a cause-to-effect relationship.

  Conclusion Top

The study concludes that maternal factors are strong predictors for the oral health of children. Upstream and downstream approaches targeting maternal awareness on oral health is the need of the hour. Intervention, education, and communication activities coupled with behavioral change communication and social behavior communication change campaigns are needed as a whole. Effective interventions should be carried out at an early age to effectively manage children's oral health problems so as to improve their oral health and subsequently the general health-related quality of life at their later stages of life.

Financial support and sponsorship

This is a self–supported study.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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