Oral health plays an important role in the general well-being of individuals, and parents’ behavior and attitudes may affect the oral health of their children. [1] Dental neglect is defined as parents’ failure to pursue the necessary dental treatment required to maintain the child’s oral health and to ensure their freedom from pain and infection as dental neglect.[2] As well neglect is the failure to take precautions to maintain oral health, failure to obtain needed dental care and physical neglect of the oral cavity.[3]
Dental Neglect is seen at each and every step of life with different reasons involved with it. Child dental neglect though appears as an isolated problem ,in reality it may be an indicator of other type of abuse.[4] Also children who suffer from poor oral health are 12 times more likely to have restricted activity days than those who do not.[5] There is clear evidence that child dental neglect impacts adulthood health regarding the elevated risk of disorders such as malnutrition .Though child dental neglect represents an isolated problem it is known that it may be a suitable indicator of other types of neglect.[6,7]
It is the responsibility of parents to pursue health related necessities of their children. In this regard, the lack of parents or guardian’s attention has destructive impact on the child’s oral status. Investigating dental neglect among children would identify the specific reason for the failure to prevent and treat dental caries. Thereby it provides the government and health care personnel to address the issue at root level.[8] World Health Organization has stated that neglect has to be distinguished from other factors which includes circumstances of poverty, implying that neglect can only occur in a situation where reasonable resources are available to the family or caregiver .[9]
Dental neglect scale (DNS)for children assesses the extent to which a parent or caretaker cares for the child's teeth, receives professional dental care, and believes oral health to be important.[10] The Dental Neglect Scale appears to be an appropriate method for objectifying dental neglect. It has satisfactory health index and easily measured, apparently unaffected by the observation process, and able to be manipulated statistically. The Dental Neglect Seale helps in predicting and understanding variation in dental health, and identifying dental health promotion strategies.[10] Parents and responsible adults are the principle actors in the children’s development in the first years of life. Thus, the interventions directed at parents’ beliefs and attitudes about oral health may be beneficial in the prevention of oral problems such as dental caries.[11]
There are various case reports, case control studies and cohort studies in the literature regarding dental neglect in children. However these studies have not evaluated the parent’s perspective regarding the child's oral care in total. [12] Hence the aim of this study was therefore to investigate the phenomenon of dental neglect in children in Chennai and to examine its association with key demographic features and dental health status.
Materials and Methods
An ethical approval for the study was obtained from the Institutional's review board. This cross sectional study was conducted for a week's time in a book exhibition program in Chennai. This ensured that participants involved in the study were randomly selected from the entire Chennai population. On the first two days of the event a pilot study which involved 100 participants was conducted and sample size for the main study was calculated using Gpower version 3.1 based on its result. The continuous variable was dichotomised in order to find the relationship between dental neglect and caries status. The mean deft score for the low and high DNS groups were 2.165 and 2.981 respectively. The estimated sample size with type I error 5% and power of a test (beta) set at 95% was 408. Considering 10% dropouts the sample size was set at 450. The participants included children aged from 3 to 12 years and the questionnaire was answered by their parents. An informed consent was obtained from the participating parents. The parents were asked to fill in a comprehensive questionnaire which included demographic details, visits to dentist and seven questions of Dental Neglect Scale. [10] Two calibrated dentists carried out the oral examination in children. Children with the consent to participate in the survey were examined in day light in an upright position. Oral examinations were conducted using a disposable illuminated mouth mirror (Denlite, Welch Allyn Ltd, Navan, Co Meath, Ireland) and a blunt ball-ended probe (Diagnostic Probe, Hu-Freidy Dental, Chicago, Illinois, USA) with an end diameter of 0.5mm. All teeth were examined in a systematic manner using international FDI two-digit nomenclature to identify each tooth and surface. Oral hygiene and dental caries status was assessed by OHI(S) index [13] and WHO [14] criteria. PUFA/pufa for permanent and deciduous teeth was calculated using the pufa index to assess the severity of untreated caries. [15]
The collected data were tabulated and subjected to statistical analysis using SPSS V20.0 and levels of statistical significance were set at p<0.05. In addition to descriptive statistics, t test were used to examine the mean DNS, deft, debris index and pufa scores according to sex, age and residential address. One – way ANOVA was used to examine the mean DNS, deft, debris and pufa index scores with respect to education, income, dental services utilized pattern. Frequency distributions of the response to DNS questions were produced. A median split of the DN score was used to divide the population into two groups that is high (DNS’17) and low (DNS’16). Then student t tests were used to compare the mean DMFT, deft, PUFA, pufa and debris scores between the low and high dental neglect groups.
Results
A total of 478 pair of parents and children participated in the study, of which female and male parents were 284 and 194 respectively. The mean age of the parents was 34.40 ” 6.54 years. Table 1 and 2 illustrates the comparison of mean dental neglect, deft, debris index, pufa, DMFT and PUFA scores of the children with respect to sex, age, education, domicile, income and last dental service utilized in years.
There was no significant difference in the mean dental neglect score with respect to sex, age and income. With respect to dental neglect scores a significant higher dental neglect score was reported among the people who reside in the suburban location (p<0.001), parents whose educational qualification were secondary (p<0.001), and those people who haven’t availed any dental service for greater than 3years (p=0.001). Post hoc tukey test revealed a significant difference in the dental neglect score between the caretakers whose educational qualification was secondary and graduate. Comparing the dental neglect and the oral health status, a higher DMFT (1.17) and debris index (1.21) score were seen in the children whose parents educational qualification were secondary. Similarly a higher debris index (1.20) score were reported in children who live in the suburban areas. Also higher mean dental neglect score (18.12) was seen in the parents age group of 30 to 39 which corresponds to the higher mean deft (2.74), DMFT(1.12), pufa (0.85), PUFA (0.29) and debris index(1.08) scores. A higher deft (2.91), pufa (1.01), DMFT(1.10) and debris index (1.08) score was reported by parents whose monthly income ranges between 10,000 to 15,000 whose mean dental neglect score was 17.92. In the dental services utilized a higher mean deft (3.184), DMFT (1.33) and debris index (0.90) scores was reported among the parents who haven’t utilized the services for 2 years.
The descriptive statistics for the response distribution in percentage to the dental neglect questions were illustrated in table 3. With respect to items 1, 2, 5 and 7 questions given in the table around 40% to 70 % of the people have responded saying ‘somewhat yes’, which means that the child is maintaining her home dental care by brushing the teeth regularly and also receives the care from the dental office. Around 37% of them responded that they somewhat don’t say no to the dental care needed for the child. In item 4 around 34% of the parents responded that the child definitely don’t neglect the dental care needed for them. Regarding parental control of snacking between the meals around 33 % reported that they are not able to control the snacking habits of the children, while another 33% reported that they are somewhat able to control the child’ between meals snacking habit.
Figure 1 illustrated the comparison of the DMFT, deft, PUFA, pufa and the debris index score between the higher dental neglect and the lower dental neglect groups. A significant higher DMFT (p=0.003), deft (p=0<0.001), pufa (p=0.011) and debris index (p=0.002) scores were seen in the higher dental neglect group when compared to the lower dental neglect group.
Discussion
There is very scarce literature regarding estimate of child dental neglect across the globe. Assessing child dental neglect among caretakers offers a linkage between dental health and socio economic factors, attitude towards dental health and acceptability to dental treatment which have hitherto received less attention. [10] This study was conducted in a common area where the participants were from various sectors of the society. Hence the results of the study can be generalised to the population of the Chennai. A systematic review suggested that common features of den”tal neglect include failure to seek or delay in seeking dental treatment, to comply with and or complete treatment and failure to implement basic oral care. Symptoms such as pain and swelling are also considered to be features of neglect.[16] Hence this study used the Dental Neglect Scale to associate various factors that could influence dental care and the oral health of a child. Dental neglect scale is an ideal instrument as it assesses both behaviour and attitude towards oral health. It serves as a good tool for population surveys aimed at identifying risk groups based on information about oral health, oral health related behaviour and attitude.[17,18,19] It is recommended that the attitude of the parents must be changed before the attitudes and dental health behavior of children can be measurably improved. [20]
In addition to recording the caries status, the severity of caries was also evaluated (PUFA and pufa), [15, 21] which interprets the degree of failure to seek dental treatment. Literature states that early carious lesion progresses to cavity in two to three years [22] and detection of precavitated carious lesions in infants and young children may predict high caries activity. [23,24] Hence white spot lesions were also recorded as caries in this study.
Since there is no available printed literature regarding dental neglect score of parents of young children direct comparison between the studies is difficult. The median DNS score among parents in Chennai is 17.9 indicating mediocre oral health care for children (out of possible range: 6-30).This is higher than those of parents in Australia[10] which can be due to availability of dental services and cultural differences between the places of study. This higher dental neglect scores is associated with poorer oral health as seen in previous reports[10,25] Lower DN scores were also seen in studies conducted among adolescents in United States[19] and Hong Kong [26].This difference could be attributed to the fact that the study was done among adolescents who are capable of taking care of themselves. The distribution of replies to the seven items suggests a difference between responses to items referring to professional care and those which explore home care.
The present study showed that as age increases among caregivers the dental neglect score is significantly higher. The importance of oral health might not have been as a lifestyle practice for elder people in this population. However we see that the present younger generation parents are more towards maintenance of good oral health similar to results obtained by Shamta Sufia et al. [27] This is a positive aspect that the trend of importance of oral health is getting rooted into the society. Hence educational strategies focused on parents of preschoolers are highly valuable, since their behaviour regarding oral health has a direct influence on the number of dental caries of their children(Okada).[28] The care takers who responded to the questionnaire were mostly mothers of the children which is in accordance to . Hence it helped us to know the complete home and professional dental care the child receives as the child is mostly with the mother during the preschool and even after the child starts to go to school. [29] The mean dental neglect score among the mothers is high suggestive of requirement of dental education as mothers are important role models transferring values, norms and attitude to their children. [30] It was found that DNS was higher among male than female though not statistically significant similar to studies done in United States [19] and Hong Kong[26] .In contrary ,higher neglect among male was seen in a study done in India which evaluated self dental neglect.[25] Hence it can be assumed that a possibility exists when individuals who show self neglect towards themselves may show neglect towards their children.
The results of the present study confirmed the fact that parents living with low incomes and who have not had higher education showed lesser levels of positive dental attitudes similar to a study done by Williams et al.[31,32] Hence there is greater predisposition for the occurrence of oral diseases in children of low-income mothers,[30 ] which is in contrary to the result of AlGahnim et al[33] where it is stated that income does not play a role in attitude towards oral health. In the present population it was observed that untreated caries resulting to pulpal involvement is seen in low income house hold. However the parents who have post graduate education showed higher dental neglect in the study. This result might be misleading as only few postgraduate parents were involved in the study.
It was observed in the present study a significant difference in the dental neglect scores among parents residing in the suburban areas in comparison with parents of urban areas. This is essentially due to lesser awareness of oral health, availability and usage of dental services. [29] Hence, the oral hygiene status and caries status is poorer when compared to children from urban areas.
The dental neglect among children is higher whose parents last dental visit was before 3 years and symptom driven which is similar to findings in South Australia.[10] The dental neglect is reflected in the poor oral health of these children with significantly higher caries prevalence and untreated carious lesions. This suggests that the knowledge of parents regarding oral health and utility of dental services is limited as the frequency of dental visits suggests the oral health awareness among parents.[34] It has been found that the more positive is the parents attitudes toward dentistry, the better will be the dental health of their children. [20] Young children’s oral health maintenance and outcomes are influenced by their parents knowledge and beliefs, which affect oral hygiene and healthy eating habits. [29]
Literature proves that poor attitude of parents toward oral health of infants and young children lead to increased caries prevalence in children.[35],as parents frame norms for tooth brushing and sugar consumption.[36] It is seen that younger mothers and with higher education have more knowledge on use of tooth paste and tooth brush. [27, 37] Though the parents in the present study state that their children brush their teeth the oral hygiene status of children does not indicate it. There exists a disparity between the observed tooth brushing habit and that reported by mothers. Hence the response of the parents regarding brushing has to be taken with caution. [38] Though more than half the parents in the study population thought they gave good home care to their children the oral health status did not support their view. This was similar to study done in Texas it has been seen that parents perceived that their children ‘took care’ of their teeth while the children reported that they had not given importance.[20] In the studied population parents were not confident about their control over the snacking habit of their children .In addition the parents assumed it is the responsibility of the child rather than themselves in terms of dietary habits. However, childhood dietary habits constitute an important factor in the etiology and progression of the carious disease. The preference for flavours occurs in the developmental phase of the child. Hence guidance from parents not only is associated with good oral habits but also in the rational consumption of sugar.[39] In addition Ferreira[40] also found that carious activity was higher in those patients who began tooth brushing without parental supervision and who began to consume sucrose before the first year of life and who eat between the main meals. Similarly the results of the present study indicate that the oral health and the caries status in children were poor whose parents showed negligence towards good brushing and snacking habit.
It was observed in the present population that 45.1% showed indifference to take professional dental care. Parents who avoid bringing their children to scheduled dental appointments and previous negative experiences for the child indicates development of risk for dental caries in 5-year-old children.[41] Even if the child shows avoidance behaviour towards dental treatment, it is the responsibility of the parents to bring young children to the dentist. The present study shows that most of the parents do not delay the treatment of their child. If a parent does not keep up to the scheduled dental appointment for their ward it reflects on the negative beliefs and attitudes towards dental care. [42] In addition parents who do not prioritise their own dental treatment will not take their child to dental examination. [42,43]
Conclusion:
Dental neglect is present among parents of Chennai city. Education and domicile plays an important role in the parent’s knowledge and attitude toward good dental care. Hence it is essential to identify the parents and children who are at risk of lesser oral care and initiate measures targeted to their needs.
Limitations
The limitation of the present study is that the dental screenings were carried out under natural light using Community Periodontal Probe and mouth mirror. Use of radiographs might be helpful to associate DNS and dental caries experience.