Community Dent Oral Epidemiol 2012; 40: 451458 All rights reserved

2012 John Wiley & Sons A/S

Childrens use of dental services: inuence of maternal dental anxiety, attendance pattern, and perception of childrens quality of life
Goettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD. Childrens use of dental services: Inuence of maternal dental anxiety, attendance pattern, and perception of childrens quality of life. Community Dent Oral Epidemiol 2012; 40: 451458. 2012 John Wiley & Sons A/S Abstract Objectives : The purpose of the study was to investigate the inuence of a childs clinical condition; maternal characteristics such as dental anxiety and dental visit pattern; socioeconomic conditions; and maternal perception of the childs oral health-related quality of life (OHRQoL) on a childs use of dental care services. Methods : A cross-sectional study of 608 motherchild dyads was conducted during the Childrens Immunization Campaign in Pelotas, Brazil. Mothers answered a questionnaire regarding their use of dental services, dental anxiety (Dental Anxiety Scale), socioeconomic status, and perception of their childrens OHRQoL (the Early Childhood Oral Health Impact Scale). Clinical examination of the children was performed to assess dental caries (dmf-t). Associations between the above-mentioned factors and child use of dental services were assessed using Poisson regression models (prevalence ratio [PR]; 95% CI; P  0.05). Results : The majority of children (79.3%) had never had a dental appointment and of the children who had visited a dentist, 55 (43.65%) presented with untreated dental caries at the time of examination. More than half the mothers (60.2%) did not visit a dentist regularly. In the nal model, low schooling level of mothers (PR, 0.64) and irregular visits to a dentist by the mother (PR, 0.48) were factors because of which a child did not have a dental appointment. Children who had experienced pain (PR, 1.56), those who had poor OHRQoL (PR, 1.49), and older children (PR, 2.14) visited a dentist with higher frequency. Conclusions : Use of dental care services by preschool children was low, and treatment was neglected even among children who had visited a dentist. Children of mothers with low schooling level who do not visit a dentist regularly were at greater risk of not receiving dental care. Maternal perception of their childs oral health motivated visits to the dentist.

lia L. Goettems1, Thiago M. Mar vio F. Demarco3, Ana R. Ardenghi2, Fla 4 Romano and Dione D. Torriani5
1 Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil, 2 Department of Stomatology, School of Dentistry, Federal University of Santa Maria, Santa Maria, Brazil, 3Department of Operative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil, 4 Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil, 5 Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil

Key words: dental care; health care disparities; oral health; preschool children lia Lea o Goettems, Department of Social Mar and Preventive Dentistry, School of Dentistry, Federal University of Pelotas, Rua Gonc alves Chaves, 457 Center 96015-560 Pelotas, Brazil Tel.: +55 53 32256741 Fax: +55 53 32224162 e-mail: mariliagoettems@hotmail.com Submitted 21 June 2011; accepted 7 March 2012

Despite the declining occurrence of dental caries, it remains the pre-eminent oral disease of childhood. Therefore, it is considered the primary marker of childrens oral health, while visits to a dentist are considered a marker of care (1). Oral health care assistance can help develop healthy oral health
doi: 10.1111/j.1600-0528.2012.00694.x

habits in preschool children to a large extent. It is recommended that a childs rst visit to a dentist happen by the age of 1 year (2). This early visit gives a dentist a chance to improve the childs oral hygiene, to correct improper dietary habits, and to improve parents knowledge. Regular visits to a

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dentist afford long-term benets in terms of higher subsequent use of preventive services and lower dental care-related expenditure (3). Dental care may also reduce inequalities in dental health among children and compensate for factors in the childs surroundings that could be associated with poor dental health (4). Specic behaviors have been identied as being associated with caries in preschool children. Most of these oral health behaviors the dental team could attempt to modify with appropriate advice to parents when they attend for the treatment of their children. (5)Therefore, it is important to understand the dental visit pattern of children. In Brazil, usually, only a small percentage of children visit a dentist at the recommended age (6, 7). Data from a national survey (PNAD) showed that 77.1% of children aged 06 years had never visited a dentist; however, children with higher socioeconomic statuses were ve times more likely to have received dental care services than did children with lower socioeconomic statuses (7). Similar ndings have been observed in other countries (8, 9). Edelstein et al. (1) assessed the trends in dental caries and use of dental care services among American children and found disparities in dental visits and oral health according to age, family income, race/ ethnicity, and caregiver education level. Characteristics such as low maternal schooling level, family attendance patterns, and presence of a healthcare system are frequently cited as barriers to dental care visits of children (7, 10, 11). Decisions regarding oral health care and health-care utilization patterns can also be inuenced by the presence of either normative or self-perceived oral health care needs. However, despite the association of psychosocial factors with the use of dental care services in adults and older children, the inuence of psychosocial factors, such as parental perceptions of the childs oral health (10) and dental anxiety, on the use of dental services in preschool children (12) is unclear. Parental characteristics, attitudes, and perceptions may not only inuence the parents own use of dental services but also their childrens use of dental services, because children depend on their parents for visits to a dentist. Therefore, this study aimed to assess the inuence of childrens clinical condition; maternal characteristics such as dental anxiety and use of dental services; socioeconomic conditions; and maternal perceptions of the childs oral health-related quality of life (OHRQoL) on a childs use of dental services. The primary hypothesis to be tested was that

maternal dental anxiety, irregular attendance pattern, and a negative perception of the childs OHRQoL were associated with childs use of dental care services.

Materials and methods

Study population and sampling procedure
A cross-sectional study consisting of children aged 25 years and their mothers was performed in the city of Pelotas during the Childrens National Immunization Campaign in June 2009. Pelotas is located in southernmost Brazil and has about 350 000 inhabitants, including 22 150 children aged 5 years or younger (13). According to the Ministry of Health, acceptance of the immunization program among children aged up to 59 months in Pelotas was 90%. Of these children, only a small percentage (4%) was vaccinated in places other than public health centers, such as schools or supermarkets. To examine the association between the use of dental services and the independent variables, we used the following parameters on the basis of parameters reported in a previous study (14): 5% standard error, 80% power, 95% condence interval, 10% nonresponse, a 2:1 ratio of unexposed to exposed, and a prevalence ratio to be detected of at least 1.8. As cluster sample selection was used, a design effect of 1.4 was estimated. The minimum sample size to satisfy the requirements was estimated to be 456 children. However, as this study was part of a larger study designed to assess the prevalence of maternal dental anxiety (15), the sample was increased to 507 motherchild dyads. A two-stage stratied sample design was used to select the sample. Of the 25 existing healthcare centers in towns that have dental ofce facilities, nine were randomly selected using a probability selection method, with probability proportional to the size of the health center. There was at least one sampling point in each of the seven administrative areas into which the city is divided. After the children were vaccinated, mothers were invited to participate in the survey, which included an interview of the mother and a dental examination of the child. Children with neurological or systemic diseases were not included.

Data collection
Twelve previously trained dental students conducted interviews with the mothers. Monthly

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family income was measured in terms of the Brazilian minimum wage, which corresponded to approximately 250 US$ at the time of data collection. Educational level was assessed by comparing mothers who had completed more than 8 years of formal education, which corresponds to primary school education in Brazil, with those who had not. Mothers were asked about their use of dental services and whether their children had ever had a dental appointment. Maternal dental attendance pattern was classied as nonregular if she answered that she (1) never goes to the dentist or (2) goes to the dentist when she feels pain or has a problem; and regular if she answered that she (3) goes to the dentist whether she has a problem or not or (4) goes to the dentist regularly (16). Maternal dental anxiety was measured using the Brazilian version of Corahs Dental Anxiety Scale (DAS) (17). It contains 4 multiple-choice items dealing with subjective reactions to visiting the dentist and other dental-related situations. Each item was scored on a scale from 1 (calm) to 5 (terried). The total score for all items ranged from 4 to 20. Mothers dental anxiety was classied as low (DAS score of 11 or less), moderate (DAS score from 12 to 14), or high (DAS score of 15 or more) (18). To assess maternal perceptions of their childrens OHRQoL, the Brazilian version (19) of the Early Childhood Oral Health Impact Scale (ECOHIS), which was developed and validated by Pahel et al. (20), was used. It consists of 13 items, including a child impact section and a family impact section. Answers were recorded using a Likert scale, with response options coded from 0 to 5 (0 = never, 1 = hardly ever, 2 = occasionally, 3 = often, 4 = very often, and 5 = do not know). The total score ranged from 0 to 52. Dont know responses were recorded as missing. For those with up to two missing responses in the child section or one in the family section, a score for the missing items was imputed as an average of the remaining items for that section (20). ECOHIS scores were dichotomized using the median value as a cut-off point. Detailed information of the impact on OHRQoL in this sample has been reported elsewhere (15). Clinical oral examinations were performed by 12 dentists, who were postgraduate students with previous experience in administering oral health surveys and who had been trained and calibrated at the School of Dentistry of the Federal University of Pelotas. Training practice was performed for a 4-h period. Then, each of the dentists examined 15 children with different levels of disease. Inter-

examiner agreement was tested against a gold standard examiner. Intra-examiner reliability was investigated by repeat examinations 1 week later (21). Kappa statistics were used to test both interand intra-examiner reliability. World Health Organization (WHO) (22) criteria, which do not include initial noncavitated caries lesions, were used for dental caries assessment. Dental examinations were performed at dental ofces in healthcare centers under articial light by using a dental mirror and a WHO periodontal probe. Biosafety principles established by the WHO were followed (22). To test the proposed methodology a pilot study involving 15 children was carried out prior to data collection.

Statistical analyses
Statistical analyses were performed using Stata version 10.0 (Stata Corporation, College Station, TX, USA). Unadjusted analyses provided summary statistics assessing the association between outcome and the independent variables. In the analyses, the use of dental services (outcome) was considered a dichotomous variable (never used versus ever used). A Poisson regression model with robust variance was used to assess the association between the predictor variables and outcome. This strategy allowed for the estimation of prevalence ratios (PR) between the comparison groups and their respective 95% condence interval (CI). A forward stepwise procedure was used to include or exclude explanatory variables in model tting. Variables with P values of  0.20 in the assessment of correlation (unadjusted analyses) were included in the model tting. For the nal models, the variables were considered signicant if they had a P value of  0.05 after adjustment. The analyses took into account the clustered sample.

Ethical considerations
This study was approved by the Human Research Ethics Committee of the Federal University of Pelotas. All the mothers gave written informed consent. Mothers were informed of the oral health status of their children, and the children who needed dental treatment were referred to the School of Dentistry.

Results
Inter-examiner Kappa values ranged from 0.85 to 0.96 (mean = 0.92), and the intra-examiner Kappa value ranged from 0.70 to 1 (mean = 0.95).

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A total of 685 mothers were invited to participate in the survey, and 92% of them agreed to participate. Of the 630 mothers who answered the questionnaire 3.5% (n = 22) were excluded from data analysis because of the childs refusal during clinical examination; therefore, a total of 608 mother child dyads were included in the analysis. The distribution of mothers and children according to demographics and family characteristics is presented in Table 1. The majority of children (79.3%) had never had a dental appointment, and more than half of the mothers (60.2%) did not visit a dentist regularly. The mean ages of the mothers and children were 29.3 years (SE = 0.29) and 43.4 months (SE = 0.49), respectively. Thirty-nine percent of the children had early childhood caries (ECC), dened as the presence of one or more decayed tooth surfaces in any primary tooth of children younger than 72 months (23). Only 1.7% of the children with dmft  1 had had restored or extracted teeth, and of the 126 children who had visited a dentist at least once, 55 (43.65%)

Table 1. Demographic and socioeconomic variables, clinical characteristics, and maternal dental anxiety and perception of childs oral health (Pelotas, Brazil; n = 608 motherchild dyads) Total Variable Sex Age (months) Category Male Female 2435 3647 4860 >60  1.5 BMW <1.5 BMW >8 years  8 years 0 1 Regular Irregular Yes No Never experienced Experienced Low Moderate High 1 >1 n 301 307 175 186 199 48 316 282 261 345 367 241 242 366 126 482 430 178 362 110 136 307 301 % 49.5 50.5 28.8 30.6 32.7 7.9 52.8 47.2 43.1 56.9 60.4 39.6 39.8 60.2 20.7 79.3 70.7 29.3 59.5 18.1 22.4 50.5 49.5

Monthly family income Maternal schooling dmf-t Mothers dental visits Child visited a dentist Pain teeth/mouth Maternal dental anxiety ECOHIS score

presented with untreated dental caries at the time of examination. Nearly half the mothers had a moderate or high level of dental anxiety, ECOHIS total scores ranged from 0 to 42 with a mean of 3.3 (SE = 0.22) and a median of 1. Three hundred and fty-eight mothers (58.9%) reported that their children had impact in at least one item on the ECOHIS. The number and proportion of children who visited a dentist according to the independent variables are shown in Table 2. In bivariate analyses, probability of having had a dental appointment was lower for children of low-income families (PR, 0.64; 95%CI 0.460.89) and whose mother had low schooling level (PR, 0.58; 95%CI 0.430.80) and irregular visits to a dentist (PR, 0.48; 95% CI 0.35 0.65) Children who had experienced pain (PR, 1.87; 95% CI 1.382.54), whose mothers had perceived impact on the childs quality of life (PR, 1.71; 95% CI 1.242.37) and older children (PR, 2.26; 95% CI 1.383.71) visited a dentist with higher frequency. In the multivariate analysis, the associations between the childs use of dental services and maternal attendance pattern, maternal schooling, the childs age, the presence of pain and perception of the childs OHRQoL were conrmed. Children whose mothers did not visit a dentist regularly were less likely (PR, 0.49) to have ever gone to the dentist than their counterparts; this probability was also lower (PR, 0.65) for children whose mothers had lower levels of education than for those whose mothers had more than 8 years of formal education. Children with mothers who reported their childs OHRQoL as poor (below the sample median) had a higher likelihood of having already visited a dentist (PR, 1.49 1.052.13).

Discussion
This study assessed factors associated with 2- to 5-year-old children who had never visited a dentist. It is worrisome that only a small percentage of these preschool children have been to a dentist. This nding is in accordance with others studies performed in southern Brazilian cities; Kramer et al. (6) showed that only 13.3% of children under 5 years of age had visited a dentist, and Ardenghi et al. (14) showed that 24.2% of children aged 5 to 59 months had already had a rst dental visit. In Mexico, Medina-Solis et al. found that only 40% of children had at least one dental visit in their life for any reason. Although these levels of utilization are

BMW, Brazilian minimum wage; ECOHIS, Early Childhood Oral Health Impact Scale; dmft, decayed/missing/ lled teeth.

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Preschool childrens use of dental care services Table 2. Factors associated with a childs dental service use (Pelotas, Brazil; n = 608 motherchild dyads) Variable Sex Male Female Age (months) 2435 3647 4860 >60 Family monthly income  1.5 BMW <0.5 BMW Maternal schooling >8 years  8 years Cavities or caries Absent Present Mother dental visits Regular Nonregular Pain teeth/mouth Never experienced Experienced Maternal dental anxiety Low Moderate High ECOHIS score 1 >1 Visited a dentist n (%) 67 (22.3) 59 (19.2) 29 (16.6) 22 (11.8) 57 (28.6) 18 (37.5) 77 (24.4) 44 (15.6) 70 (26.8) 54 (15.6) 71 (19.4) 55 (23.2) 73 (29.9) 53 (14.5) 71 (16.5) 55 (30.9) 84 (23.2) 21 (19.1) 21 (15.4) 47 (15.3) 79 (26.3) PR crude (95% CI) 1.00 0.86 (0.631.18) 1.00 0.71 (0.431.19) 1.73 (1.162.57) 2.26 (1.383.71) 1.00 0.64 (0.460.89) 1.00 0.58 (0.430.80) 1.00 1.21 (0.881.66) 1.00 0.48 (0.350.65) 1.00 1.87 (1.382.54) 1.00 0.82(0.541.26) 0.67 (0.431.03) 1.00 1.71 (1.242.37) P value PR adjusted (95% CI) 1.00 0.75 (0.451.23) 1.79 (1.222.63) 2.14 (1.30-3.54) 1.00 0.65 (1.191.65) 1.00 0.49 (0.350.68) 1.00 1.56 (1.112.19) 1.00 1.49 (1.052.13) 0.03  0.01 0.01  0.01 0.23  0.01  0.03 P value

0.35 0.20  0.01  0.01  0.01  0.01 0.23  0.01  0.01 0.37 0.06  0.01

BMW, Brazilian minimum wage; ECOHIS, Early Childhood Oral Health Impact Scale; PR, prevalence ratio.

considered low, they are higher than those in the present study (24). Despite increasing efforts to begin dental care very early in life, when primary prevention of dental caries is possible, very few children receive early care (1). Parents bear the responsibility of taking preschool children to the dentist. The results of this study showed that maternal attendance pattern is a predictor of childrens use of dental services. Because young childrens dental health relies on parental involvement and support from dental services (4), children whose mothers do not use dental services on a regular basis can be considered at risk. Crawford and Lennon found that, in a deprived area, a mothers attendance was a good predictor of childrens attendance, although a substantial proportion of mothers who did not visit the dentist themselves did ensure the attendance of their children (25). Previous studies have detected an association between a childs dental visits and parental visits to dentist for preventive reasons and the recency of their caregivers dental visits (26, 27). Further, Isong et al. (28) found that parents

who did not obtain dental care for themselves were less likely to seek dental care for their children. It is known that an individuals health decisions are inuenced by previous experience (29). Therefore, it is likely that a mothers negative perception or previous negative experience of dental treatment inuences not only the mothers dental care use but also dental care use by the child. A negative association was found between dental anxiety and use of dental services in adults (12). In a sample of preschool children, it was found that mothers who were relaxed about their own dental care were most likely to have preschool children who were registered for dental care (27). Thomas and Startup (30) examined the impact of a mothers dental anxiety level on her childrens dental health: it was not only shown to block the provision of adequate care, but also led to dental neglect. To our knowledge this is the rst study to use a validated tool and a multivariate approach to assess whether maternal dental anxiety is associated with treatment avoidance in preschool children. Results showed that, more frequently, mothers with a low

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level of dental anxiety had children who had visited a dentist, but this difference was not statistically signicant. The childrens own fear related to dental care was not assessed, and this factor could be more important than maternal anxiety of dental visits. The inuence of demographic characteristics, clinical variables, and socioeconomic conditions was also assessed. Similar to other studies, an association was found between age and the use of dental services (6, 24). However, it is important that further studies assess whether this is associated with the parents perception of the need for a preventive appointment or whether they took the child because of the appearance of symptoms or presence of oral health problems that became more prevalent with age (6). The utilization of dental services by children and adolescents is often driven by the presence of pain (31). In this sample, having experienced pain did inuence parents taking their children to the dentist, whereas having teeth affected by caries did not. However, only 30.9% of children who experienced pain were taken to the dentist. Maternal perception of their childs OHRQoL was associated with utilization of dental services, conrming the fact that greater oral health need (perceived or normative) is an important predictor of use of dental health services in preschool children (24). For the youngest children, such as those investigated in this study, a proxy rating by caregivers is indispensable to document the consequences of oral disorders, and it is understandable that poorer perception is an indicator for parents to take their child to the dentist. This is in agreement with observations by Sohn (26); caregivers unfavorable perception of their childrens oral health motivated them to seek dental care for them. In contrast, a contradictory result was found by applying a questionnaire to older children; those who rated their oral health as good/excellent were more likely to have visited the dentist (10). It is known that children from low-income families tend to have the greatest needs and lowest use of dental services (1). Therefore, there are fewer opportunities for dentists to intervene in cases of these patients who are at maximum risk. It is important to consider that, although public access to dental treatment has spread to greater segments of the Brazilian population, this young population (age, 05 years) is underserved in terms of public dental services (32).

Maternal schooling level was a determinant factor of a child having visited a dentist. This is understandable, as the knowledge and skills attained through education may affect a persons cognitive functioning, making them more receptive to health education messages or more able to communicate with and access appropriate health services (33). According to Mello and Antunes, there may be a lack of parental knowledge about the importance of deciduous dentition (34), and some parents might believe that the teeth of children at this age are not important because of their temporary nature. In many countries restorative treatment in primary teeth is suboptimal (35). In a Brazilian oral health survey performed in 2003, 80% of 5-yearold children presented with untreated dental caries (36). In the present sample untreated cavities were detected in 98.3% of the children who presented with the disease. With regard to the frequency of restorative dental treatment, the high occurrence of untreated caries in this population is alarming and could be the result of low utilization. However, even children who visited a dentist did not receive rehabilitation treatment. This has also been observed by Sohn et al. (26), who concluded that this nding could be reective of the fact that children who received restorative treatments or underwent extractions did not receive proper therapy to prevent further development of dental caries. It has been reported that, when combined with preventive care, if left unrestored the majority of carious deciduous teeth exfoliate without the child visiting his/her dentist for pain and infection (37). Nevertheless, primary teeth of young children are vital to their development, and every effort should be made to retain these teeth for as long as is possible, because there is no evidence that no treatment is better than dental llings for the treatment of caries in the primary dentition (38). The early intervention has great potential to reduce the overall costs associated with dental treatment in preschool children (39). However, it is important that further studies assess the effects of early preventive visits on oral health outcomes and the reasons why children do not visit a dentist by the recommended age. Studies on the use of dental care may help understand and predict behavior, and consequently, help establish public health policies that encourage the use of dental care at an early age (6). Understanding the impact of socioeconomic and psychosocial predictors of oral

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health care use may lead to better allocation of resources (40). Finally, it can be concluded that there was low utilization of dental services by preschool children and untreated dental caries were present even among children who had visited a dentist. Children of mothers with low schooling level who do not visit a dentist regularly were at greater risk of not receiving dental care. Maternal perception of their childs oral health motivated visits to the dentist.

14.

15.

16.

17.

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