Oral health information for Appalachia-West Virginia children: a cross-sectional analysis

Abstract

Introduction

Researchers, using a large, national, representative data base, reported an increase in caries in young children in the US[1]. They reported that poor oral health remains an important public health issue particularly for the young. Although dental caries is the most common chronic childhood disease, it has been reported that parents/guardians have not given significant attention to prevent the occurrence of caries at early ages [2]. Poor parental knowledge, attitudes and beliefs have been associated with dental caries in children [2]. Parental knowledge, attitudes and beliefs may influence the trajectory of oral health care throughout a child’s life [2]. Additionally, the Surgeon General, in the Report on Oral Health in 2000, indicated that several deaths were associated with caries-related sepsis, and although the numbers are unknown, there are concerns that a number of deaths were associated with anesthesia for dental treatment [3]. Caries in children under age 60 months is a challenge in vulnerable populations, such as the poor and near-poor, where the dental caries prevalence approaches 50% [3].

Anticipatory guidance in medicine is the provision of information to parents/guardians to help them improve their children’s development and determine potential special needs; it also involves encouraging the establishment of a medical home[4]. The aim of the approach is to intercede before challenges and poor habits develop or become permanent[4].

A similar approach is advocated in dentistry [4]. The early establishment of a dental home has been a hallmark of dental anticipatory guidance since the early 1980’s [5]. Similarly, the encouragement of parents/guardians to have a child’s first dental visit before his or her first birthday is a feature of anticipatory guidance to encourage andinitiate healthful behaviors. Dentists and dental hygienists have important roles in the provision of relevant oral health educational material/information for primary prevention [6]. One study concluded that educational and preventive instructions provide very important means by which to reduce the risk of dental caries in children [7].

The objective of this study was to determine if parents/guardians of children in Appalachia-West Virginia report that their dentists or dental hygienists have provided dentally related information at their last visit, and to determine if there is an association of having received the dentally related information with the outcome of having taken their youngest child for a dental visit within the year. The rationale for the study is that there are 1] time constraints in dental offices; and 2] dental professionals and staff have more complicated and challenging duties than in the past resulting in the potential that dental education may be overlooked [8]. It is important to determine if providing dentally related information impacts behavior.

Methods

This study was approved by the West Virginia University Institutional Review Board (number 1402219898). Researchers conducted a survey of participants attending a health fair in a shopping mall. The survey was presented for the researchers to determine if parents/guardians were receiving information with respect to a child’s dental needs, and if there were a relationship between the delivery of the information and the utilization of dental services. The inclusion requirements were that the participant was 18 years or above and that the participant was a parent/guardian of a child. No incentives were provided to the participants. Sixty-three parents/guardians were recruited, and 62 (98.4%) agreed to complete the short survey.

The survey included the behavioral outcome of interest: if the participant’s youngest child had a dental visit within the previous year if the child was older than 6 months (no vs. yes).

The advice/information from the dentist/dental hygienist was assessed through 7 individual (yes vs. no) questions and through a summative score of the questions with a cut-point of 5. The questions were developed by dental professionals. The cut-point represented a score of 71%.

Additionally, demographic questions were asked about the participant’s sex, education, race, age of the youngest child, and number of children.

The data were analyzed with IBM SPSS Statistics 21 software (IBM, Chicago, USA) for frequency/descriptive statistics. The data were analyzed with Chi Square test and logistic regression on dental visits.

Results

There were 62 participants in the study (Table 1). There were 34 (54.8%) females, 7 (11.3%) males, and 21 (33.9%) did not indicate sex. Similarly there were 36 (58.1%) participants who reported being white, and 26 (41.9%) who reported being black, other race, or who did not report race. The responses of Non-Hispanic black, or other races were aggregated with the category of not reporting due to the low response and potential for identification. There were zero participants with an education less than high school graduate, 12 participants (19.4%) who graduated from high school or earned a GED, 14 participants (22.6%) who had some college or technical school, and 35 participants (56.5%) who had a college, or technical school degree or above. There were 16 (25.8%) participants who had 1 child, 33 (53.2%) participants who had 2 children, and 12 (19.3%) participants who had 3 or more children. Considering the youngest child in the family, 7 [11.3%] participants reported that the youngest child had caries within the year and 13 [21.0%] participants did not have a dental visit within the year.

The items in the survey had a Cronbach’s alpha of 0.837 and a mean inter-item correlation of 0.439. The mean summary score was 4.8 of a possible 7 (standard deviation=2.3).

The responses to the question concerning the information/advice given by dentists/dental hygienists are presented in Table 2. There were more than 60% of respondents affirming that dentists/hygienists had given information about the effect of sugary foods, drink, and sodas on teeth; that a soft-bristled brush should be used; that one should brush 2 times a day for at least 2 minutes; that an adult needed to brush a child’s teeth until age 6 or 7 years, and that fluoride is added to the water supply to help remineralize teeth. Fewer than 60% of respondents reported being advised of the amount of toothpaste to use for a child’s age, or that sharing food utensils has the possibility of transferring bacteria involved in caries.

The Chi-square relationships of the questions, education, number of children, and caries at the last dental visit are presented in Table 3. Significant associations were with education, advice to limit sugary foods, drink and soda, advice to brush 2 times a day for at least 2 minutes, advice for an adult to brush a child’s teeth until age 6 or 7, and that fluoride is added to the water supply to help remineralize teeth. There was also a significant association of the summative score and last dental visit.

The data were analyzed with logistic regression on dental visit. The results of the unadjusted and adjusted analyses are presented in Table 4. The variables, education and summative score (which were significant in the Chi-square analysis) were included in the adjusted logistic regression analysis using the method, enter. In the final model (model significance=.009; −2 Log likelihood = 46.727), both education (p=0.057) and summative score (p=0.041) remained associated with a child having had a dental visit within the previous year. Compared with participants who had graduated from college or technical school or had a higher education, participants who had graduated from high school or had a GED were less likely to have had a dental visit for their children within the previous year. The adjusted odds ratio (AOR) was 2.5; and the 95% confidence interval (CI) was 0.4, 14.2 (p=.309). Participants who had some college or technical school had an AOR=8.6 (95%CI=1.5, 50.4; p=.017). Compared with participants who had a higher summative score, participants with a lower summative score were less likely to have had a dental visit for their children within the previous year (AOR=6.2; 95% CI=1.1, 35.4, p=.041).

Discussion

The results of this study were an association involving increased odds for an Appalachia-West Virginia child having had a dental visit within the year when dentists/dental hygienists present oral health information to parents/guardians at their last dental visit. Similar results from a study conducted in the United Kingdom support these results [9]. Although the researchers of that study used a different behavioral outcome, the researchers’ results indicated that the provision of dental health education resulted in fewer caries in infants and young children [9]. The research concerning dental communication and behavior is limited, despite the awareness of the importance of providing oral health educational information to parents/guardians [10].

The researchers for this study found 81.6% of participants indicated that their dentist/dental hygienist addressed >50% of the items on the survey (a proxy of knowledge as indicated by the respondents remembering the items). Another study of maternal knowledge of causal and preventive factors in dental caries and gingivitis indicated that 83.4% had medium to high knowledge (>50%) [11].

Parents/guardians need to receive appropriate anticipatory guidance for their children, however access to parents/guardians is often problematic. Recent trends reported by the American Dental Association Health Policy Resources Center (based on 2011 data) were that 35% of the US population had a physician’s visit, but did not have a dental visit; and 1 in 10 people visited his or her dentist but did not have an interaction with the rest of the health care system within the year [12]. As examples, there were 60% of children ages 1 through 4 years who visited a physician within the year, but did not visit a dentist; 25% of children 5–20 years who visited a physician within the year, but did not visit a dentist; 30% of adults 21–34 years who visited a physician within the year, but did not visit a dentist; and 46% of adults 65 years and above who visited a physician within the year, but did not visit a dentist [12]. The Affordable Care Act will be transformational in its emphasis on interprofessional collaboration for disease prevention and measureable health care outcomes [12]. Dental messages will be delivered in medical settings. The provision of patient information will become very important, particularly with improved monitoring of quality of care (as it is in the UK) [10]. It is imperative that dental providers offer and reinforce dental knowledge to their patients. Dentists/hygienists as well as other healthcare personnel need to develop communication skills to improve the quality and amount of information to be given to patients so that they can understand and retain the message as well as increase satisfaction, compliance, reduce fear, and increase preferred behavioral outcomes, such as dental visits [10].

Future studies are needed to consider means by which to motivate and empower parents/guardians to behaviors which are pro-active in caries control. The researchers will need to consider the current status of dental education provided by dentists/dental hygienists to determine changes and appropriate interventions to improve children’s oral health [13]. This study adds to the literature the benefits of routine discussions with parents/guardians in improving the dental visit frequency of the children of those parents/guardians. The study’s sample size is an appropriate size for logistic regression with the independent variables of education and summative score, however if more variables were to be considered, the sample size would need to be increased. The study (cross-sectional) design is appropriate for the epidemiological evaluation of education provided and dental visit, however the design does not allow for the determination of causation or temporal sequence. For those items to be considered a randomized controlled trial would with an increased sample size would need to be designed and conducted.

Conclusion

Although it is difficult to determine the anticipatory guidance that parents/guardians need at any specific point in time, it is the dentist/dental hygienist’s responsibility to help the parent/guardian to realize the intangible, long-term benefits of routine dental visits, and to give parents the ability to understand the best treatment options for their children [14].

Acknowledgments

Footnotes

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