The impact of socio-behavioral factors from the family environment on dental care affection of school-aged children

Summary

The aim of the paper: to study the impact of socio-behavioral factors from the family environment on the dental caries damage of school-age children.    

Material and methods. In the case-control study, 164 children with a mean age of 12 ± 6.29 were clinically examined. The research group (L₁) included 82 subjects affected by dental caries. The control group (L₀) consisted of 82 children free of caries. Indices of carious experience have been studied. Socio-behavioral factors in the family environment were collected by the questionnaire method. The study was conducted in accordance with ethical requirements. The analysis of the obtained data was performed using parametric and non-parametric tests of Excel and Epi Info Software. In order to determine if there are associations between the studied variables, the Spearman correlation coefficient was estimated.

Results. A strong relationship has been established between indicators of dental caries damage and the following factors: lack of parental verification of oral hygiene (ρ = 0.76, p <0.01), the level of education of the mother (incomplete middle studies (ρ = 0.74, p <0.001) and rural living environment (ρ = 0.71, p <0.001) and moderate relationship between DMFT and the number of children in the family greater than 3 (ρ = 0.59, p <0.001) and the materially socially vulnerable status of the child’s family of origin (ρ = 0.66, p <0.01).

Conclusions. The identification of socio-behavioral risk factors in the family environment is relevant for the creation of health policies to address the needs of the population, with the establishment of a hierarchy of priority care and evaluation of sources allocated for the implementation of oral health programs, dental treatment and of preventive measures.

Keywords:  dental caries, socio-behavioral factors, family environment.

Introduction

Tooth decay is a major public health problem and is the most common chronic disease [1]. According to the WHO, dental caries affects about 60% to 90% of children and adolescents worldwide [2]. In children in the Republic of Moldova, dental caries is found in the proportion of 72.04% – 89.96% and due to the high frequency and local, loco-regional and general complications it causes, it is a complex problem not only in terms of medical, but also social [3].

Several studies have reported a high prevalence of dental caries in developing countries compared to developed ones, including the lack of implementation of preventive measures, sanogenic behavior in the family environment and insufficient parental attention to children’s needs for preventive and restorative dental treatments. These data indicate the low effectiveness or insufficient funding of oral health programs, as well as the need for effective preventive strategies, educational programs and modern methods to improve oral health, especially for children whose families have a disadvantaged socioeconomic status. and low incomes [4-10].

Socio-behavioral factors significantly influence dental conditions. Previous studies have confirmed that there is an association between children’s socio-economic status and oral health. Arguments in favor of the need to analyze the relationship between socio-behavioral factors and dental caries in children, were brought by Zmarandache D., Luca R., 2016, Petersen P. E., Ogawa H., 2016, Arantes R. et al., 2018 [11-13]. Leous P. et al., 2015, concluded that the health of the oral cavity in children is determined in proportion of 10-20% by the level of dental care and 80-90% by: personal habits, socio-economic living conditions, quality of food , the state of health, the level of education of the parents, the sanogenic environment within the family, etc. [14]. The family is the natural and essential environment that influences and must guarantee the harmonious development of the child. For these reasons, it is appropriate to conduct a study of cariogenic risk factors, including social and behavioral risk factors, which will be important for the individualized prediction of dental caries and the selection of personalized preventive measures targeted at identified cariogenic factors. implemented in oral health programs.

The aim of the paper: to study the impact of socio-behavioral factors from the family environment on the dental caries of school-age children.    

Material and method

The study was conducted during the years 2021-2022 in the Department of Pediatric Oral and Maxillofacial Surgery and Pedodontics „Ion Lupan” of USMF “Nicolae Testemitanu” and in the project State Program: „Modern personalized surgery in diagnosis and complex tumor treatment in children” (20.80009.8007.06). In order to achieve the objective of the paper, a case-control clinical study was performed on a sample of 164 children aged 12 years, with a mean age of 12 ± 6.29 years. The research group (L₁) included 82 subjects affected by dental caries. The control group (L₀) consisted of 82 children free of caries. The research and control groups were identical according to the structure (Table I).

Table I. Distribution of children into groups by sex and living environment

Clinical data for the assessment of carious experience indices were collected in accordance with the criteria of the World Health Organization (WHO). Dental prevalence indices (PI), DMFT and DMFS were estimated. The state of oral hygiene was assessed using the OHI-S oral hygiene index (G. Green, I. Vermillion 1964) [15-17].

The socio-behavioral factors in the family environment were collected by the questionnaire method, being applied its indirect administration. The usual language was used in the questionnaire, the questions were closed, short, neutral, clearly worded, and in order not to cause confusion, the negations in the questions were avoided. The questionnaire was structured in 4 compartments that included questions related to:

1. general and demographic data of the respondents: sex, age, place of birth, living environment,
2.  the number of children in the family, employment and parental education,
3. oral hygiene skills,
4. eating habits and preferences,
5. access to dental care.

The data regarding the composition and material status (income) of the families of origin were noted according to the results of the expertise of the social protection commission entered in the individual files of the students included in the study, with the protection of personal data.

Criteria for inclusion in the research: children aged 12 years, coming from areas with fluoride content in drinking water in the limits of 0.8-1.0 mg / l, informed consent in writing of parents or legal representatives for the participation of children in the study .

Exclusion criteria from the study: children from endemic areas of fluorosis, suboptimal fluoride content in drinking water, lack of informed consent of parents or legal representatives for the participation of children in the study.

The study was approved by the Research Ethics Committee of USMF “Nicolae Testemitanu” and conducted in accordance with ethical requirements, with the written consent of the children’s parents. The analysis of the obtained data was performed using parametric and non-parametric tests of Excel and Epi Info Software, with the help of their functions and modules. Statistical processing of the results included operative methods of statistical evaluation, including the Student criterion with the establishment of the significance level “p <0.05”. In order to establish if there are associations between the studied variables, the Spearman coefficient ρ (rho) was used, obtained by the non-parametric Spearman rank correlation test and the 95% confidence interval for the correlation coefficient.

Results

The subjects observed were natives and residents of the Republic of Moldova. Of the 82 children affected by dental caries, 40 (48.78 ± 5.52%) were female and 42 (51.22 ± 4.48%) were male, 44 (53.66 ± 5, 51%) from rural areas and 38 (46.34 ± 5.05%) – urban. The control group was selected with an identical structure by sex, age groups and living environment (Table I).

According to the data presented in table II, in the children from group L₁ the values of the indicators that reflect carious experience were: DMFT = 4.22 ± 0.08 and DMFS = 6.04 ± 0.11. The analysis of the structure of the DMFT index in the 12-year-old children examined was: 2.7 ± 0.11 for component “D” (untreated carious cavities), the largest contributor to the index, followed by component “M”: 0.42 ± 0.49, which indicates the number of teeth extracted as a result of dental caries complications, and the “F” component (number of clogged teeth) was only 1.48 ± 0.33. In a large part of children affected by dental caries (59.76 ± 5.31%) untreated carious lesions were found, at 17.07 ± 4.15% – permanent teeth extracted and only at 23.17 ± 3, 32% of subjects had all carious lesions resolved.

Table II. Values of indicators of carious experience in children

Following the evaluation of the state of oral hygiene, it was found that in children with dental caries the average value of the OHI-S index was 1.63 ± 1.17, being 1.36 times higher than in caries-free subjects (1, 2 ± 0.22, t = 2.2254, p <0.05). In children from group L₀, good oral hygiene predominates (51.22 ± 5.52%), and in children from L₁ – satisfactory condition (40.24 ± 5.41%). Unsatisfactory oral hygiene was assessed at 20.73 ± 4.48% of children in group L₁ and 13.41 ± 3.76% of children in L₀, and poor hygiene, respectively, at 8.54 ± 3.09% between subjects in L₁ and 4.88 ± 0.24% of L₀ (Table III).

Table III. State of oral hygiene in children

The analysis of the data collected from the individual files of the students revealed a significantly lower number of children with tooth decay from whole families (59.76 ± 5.51%, p <0.001), compared to subjects without carious lesions (80.46 ± 4.38%). It should be noted that most children from incompete families were educated in the permanent or temporary absence of the father (31.7 ± 5.14% children from L₁, p <0.05 and 18.29 ± 4.23% children from L₀). 4.88 ± 2.38% of subjects with tooth decay increased without both parents, being under the tutelage of grandparents, and 3.66 ± 2.07% of children in L₁ and 1.22 ± 1.21% in L₀ – in the absence of the mother, the parents being gone to work abroad or deceased.

Most of the studied children, both from the research group and from the control group, came from families with a satisfactory material status (income). At the same time, a large number of children from the L₁ group were educated in disadvantaged families, with very low incomes, with 3-5 or more children and existed in precarious living conditions. Thus, 19.51 ± 4.38% (p <0.001) of the children affected by caries came from socially vulnerable families, and 23.17 ± 4.66% (p <0.001) of the children from group L₁ and 8.54 ± 2.08% of L₀ – from families with an unsatisfactory financial situation and very low income (Table IV).

Table IV. The socio-economic status of families of children

At the time of the interview, 30.49 ± 5.08% (p <0.01) and 47.56 ± 5.51% of the parents of children from L₁ and L₀, respectively, were present in the Republic of Moldova. In 28.05 ± 4.96% of incomplete families in L₁ and 39.02 ± 5.39% in L₀, one or both parents were missing due to migration to work abroad. At the same time, in the group of children affected by dental caries was significantly higher the number of mothers temporarily unemployed or housewife (37.8 ± 5.35%, p <0.001), compared to the group of children free of caries (18, 29 ± 4.27%).

Mothers of children affected by tooth decay have a lower level of education, compared to mothers of children free of caries: higher education – 20.73 ± 4.48% (p <0.001) compared to 40.24 ± 5.41%; incomplete higher education – 24.39 ± 4.74% (p <0.01) compared to 26.83 ± 4.89%. Respectively, in L₁ the number of mothers with secondary professional education is higher, in 43.9 ± 5.48% of cases (p <0.01) as opposed to 29.27 ± 5.02% in the control group. The level of education of fathers is also lower in L₁, compared to children in L₀, but the differences are less obvious.

Analysis of the data of the questionnaire compartment regarding the hygiene of the oral cavity (table V) shows that the majority of studied children, 47.56 ± 5.51% (p <0.01) of the research group and 65.85 ± 5.24 % of the control performed brushing only once a day. A large number of children with tooth decay performed irregular tooth brushing, several times a week (21.95 ± 4.54%, p <0.01), on a case-by-case basis (14.63 ± 3.9%, p <0.05), and 6.1 ± 2.64% of respondents mentioned that they usually do not brush their teeth. Only 9.76 ± 3.28% (p <0.001) of caries-affected subjects and 17.07 ± 4.15% of caries-free subjects brushed their teeth twice a day. Most of the interviewed children (71.96 ± 4.96%, p <0.01 from L₁ and 58.54 ± 5.44% from L₀) applied an incorrect toothbrushing technique, performing horizontal movements.

Children with carious lesions from low-income families did not have toothbrushes in proportion of 2.44 ± 1.67% and toothpaste, respectively 12.2 ± 3.6% (p <0.01), some of respondents exceeded the term of use of toothbrushes up to 6 months (59.75 ± 5.31%, p <0.001), 1 year (7.32 ± 2.88%, p <0.05) or up to their complete wear (3.66 ± 2.07%). And caries-free children exceeded the duration of use of toothbrushes up to 6 months in the proportion of 15.85 ± 4.02% or 1 year – 2.44 ± 1.67%.

A large number of respondents from the research and control groups did not know the composition of the toothpastes they used (84.14 ± 4.03%, p <0.05 and 73.17 ± 4.89%, respectively).  They indicated that they used fluoride toothpaste to sanitize the oral cavity only 3.66 ± 2.07% (p <0.001) of L₁ children and 23.17 ± 4.66% of L₀ subjects. Toothpicks were the most frequently used oral hygiene auxiliaries by children: 52.44 ± 5.51% (p <0.01) in L₁ and 26.83 ± 4.89% in L₀. At the same time, dental floss was used only by 8.54 ± 3.09% (p <0.001) of the respondents in the research group and 29.83 ± 5.05% of the control group. Of the oral remedies for oral hygiene, the most frequently used chewing gums without added sugar by 59.76 ± 5.41% of children in L₁ and 56.1 ± 5.48% of subjects in L₀ and water by mouth, in proportion of 14.63 ± 3.9% (p <0.01) in L₁ and 23.17 ± 4.66% in L₀.

The results of the study indicate that only 14.63 ± 3.9% (p <0.01) of parents at least once a week checked the hygiene of the oral cavity of children in L₁ and 24.39 ± 4.74% in those in L₀. At the same time, in most cases the parents did not check the toothbrushing of the interviewed children in 40.24 ± 5.41% (p <0.001) of cases in L₁ and 26.82 ± 4.89% of cases in L₀, or occasionally check the hygiene of the oral cavity: in 30.49 ± 5.08% (p <0.001) of children in L₁ and 9.76 ± 3.22% in L₀.

Table V. Children’s oral hygiene skills

Data on children’s eating habits, assessed by the questionnaire used, indicate a high carbohydrate intake of caries-affected subjects (60.98 ± 5.86%, p <0.001), as opposed to caries-free subjects. Only 3.66 ± 2.07%, p <0.01 of L₁ children consume carbohydrates 1-2 times a week. Most frequently, the subjects in the research group usually take snacks outside the main meals, 4-5 times a day (39.02 ± 5.39%, p <0.001), 6 and more times a day (23, 17 ± 4.66%, p <0.001), 40.24 ± 5.41%, p <0.001 of them prefer to consume carbonated drinks, sweetened juices – 24.39 ± 3.35%, p <0.05, and milk – only 8.54 ± 3.09%, p <0.001 (Table VI).

Table VI. The eating habits and preferences of the children included in the study

Of the total number of children affected by caries, the majority – 37.81 ± 5.35% (p <0.001), never benefited from a dental consultation, as opposed to 12.19 ± 3.61% of children without no carious lesions. Considering the reason that determined the last visit to the dentist, it is found that children from L₁ made, to a small extent, preventive visits – only 13.41 ± 3.76% (p <0.01), of those who appealed. A small number of subjects affected by dental caries (26.83 ± 4.89%, p <0.001) were examined for preventive purposes in school, as opposed to 46.34 ± 5.05% of cases in L₀. At the same time, 40.24 ± 5.41% (p <0.001) of children with carious lesions addressed the dentist only in cases of emergencies, following complications of dental caries, as opposed to 2.44 ± 1.67% of children from the control group who addressed in an emergency following some traumas (tab. VII).

Table VII. Access to dental care

In order to assess whether there is an interdependence or connection between the socio-behavioral factors in the family environment and the dental caries of school-age children, a correlation analysis was performed. Since some variables appreciated by us did not have a Gaussian distribution, but can be ordered, without having a large number of equal values, a specific phenomenon for medical and social studies, in this study we used the coefficient ρ (rho) Spearman, obtained by the non-parametric Spearman rank correlation test. This correlation was estimated in the conditions of inhomogeneity of the group, or of the too small number of subjects (under 20). In the statistical analysis of the study results, this test was applied taking into account the ranks of the subjects that were established by converting the results obtained into ranks. Rankings show the place of each individual in a ranking. For the analysis of the obtained results, the 95% confidence interval (CI) was calculated for the correlation coefficient, taking into account that ρ is significant when the confidence interval does not contain the value 0. How to interpret the Spearman correlation coefficient, ρ and the correlation force is presented in Table VIII.

Table VIII. Interpretation of the Spearman correlation coefficient, ρ and the correlation force

As a result of the correlational analysis of 93 variables with carious experience indicators, statistically significant relationships were estimated with only 12 variables (Table IX). Thus, high values of the correlation coefficient, Spearman, and, respectively, the strong positive relationship between the indicators of tooth decay and the following socio-behavioral risk factors in the family environment were found: lack of parental verification of oral hygiene ( ρ = 0.76, p <0.01), mother’s level of education (incomplete high education (ρ = 0.74, p <0.001) and rural living environment (ρ = 0.71, p <0.001).

Table IX. Relationship between tooth decay impairment indicators and socio-behavioral risk factors in school-age children (Spearman correlation coefficient, ρ)

Mean values of the correlation coefficient, Spearman, and moderate positive correlations were found between the indicators of tooth decay and: the number of children in the family greater than 3 (ρ = 0.59, p <0.001) and the social status. vulnerable family of the child’s origin (ρ = 0.66, p <0.01). At the same time, the moderate negative correlation between the children’s urban living environment and the indicators of carious experience was estimated (ρ = -0.60, p <0.01). The small (ρ = 0.2-0.4), very small (ρ = 0-0.2) or statistically insignificant (p> 0.05) values of the Spearman correlation coefficient do not suggest an association of the studied variables and the indicators of carious experience.

Discussions

Systematic monitoring of children’s oral health is a major component of the population health care system [2, 15]. The study of the prevalence and intensity of dental caries in children in Western European countries and in some Eastern European countries showed a tendency to continuously reduce the degree of morbidity due to dental caries [2, 14]. However, currently in 12-year-olds the values of DMFT exceed the European average of about 1.5 times in, and in most localities in the Republic of Moldova there is no reduction in this indicator, compared to the values estimated 10 years ago [3].

Now, not only the development and implementation of primary dental caries prevention programs are not sufficient, but it is also necessary to identify the factors that could reduce the effectiveness of these programs. The identification of cariogenic risk factors are accessible and inexpensive “tools” for identifying circumstances that could limit the effect of prophylactic measures implemented at Community level. Taking into account the considerable inequalities in the development of children from family backgrounds with different socio-economic status, found in the Republic of Moldova [18], we considered necessary to study the impact of social and behavioral factors on dental caries of 12-year-olds.

The results of the examination of children during the years 2021-2022 showed increased values of indicators of carious experience. Thus, the value of the DMFT index in 12-year-olds exceeded 2.81 times the WHO targets for 2020. At the same time, another important criterion was significantly increased (0.42 ± 0.49) – “the lack of permanent teeth extracted in children until at 18”, which reflects children’s access to dental treatments and the quality of dental care. Therefore, the current study shows the inadequacy of dental care for children, solving cases of complicated caries and even simple caries through tooth extractions, lack of adequate treatment in the early stages of the caries process, insufficient implementation and / or reduced effectiveness of preventive measures [18].

The share of children who went to the dentist, or were examined for preventive purposes characterizes the accessibility of dental services, which should be greater than 60%. Of the total number of children affected by dental caries, only 13.41 ± 3.76% benefited from preventive measures and 19.52 ± 4.38% from dental treatment, mainly children from urban areas. This was largely influenced by the limited access to dental care for economic reasons, the lack of motivation to perform dental treatment, and, consequently, the postponement of dental treatment until the onset of severe symptoms at 40.24 ± 5.41% of children affected by tooth decay.

Children’s oral hygiene skills were reflected in the answers to the questions of the questionnaire used in the study. From the children’s answers we deduce that among the causes of irregular sanitization of the oral cavity are the lack of toothpaste and toothbrushes in the proportion of 12.2 ± 3.6%, or the considerable exceeding of the terms of use of toothbrushes at 59.75 ± 5, 31% of respondents, mostly from families with an unfavorable material condition or socially vulnerable. Another group of factors that significantly influenced children’s oral hygiene skills were the behavioral particularities of the family environment and the lack of a favorable sanogenic environment, which is usually created by the parents and is directly dependent on their level of education. especially of mothers. This was confirmed by the lack of verification of the toothbrushing of 40.24 ± 5.41% of the parents of children affected by tooth decay or the verification only occasionally in 30.49 ± 5.08% of cases, as well as the frequent consumption of carbohydrate-rich foods of 64.63 ± 6.48% of children affected by tooth decay.

In the present study, it was analyzed whether there is an interdependence or connection between socio-behavioral factors in the family environment (93 variables) with indicators of carious experience in 12-year-old children. The objectives of the correlation analysis were to establish the direction (positive or negative) and the shape (linear, nonlinear) of the relationship between the different characteristics, to measure its tightness and, finally, to check the significance level of the correlation obtained. For this purpose, the rank correlation coefficient, proposed by K. Spearman, was used. As a result of the analysis, a strong positive relationship was found between the indicators of tooth decay and the following socio-behavioral risk factors in the family environment: lack of parental verification of oral hygiene, mother’s level of education (incomplete higher education) and rural areas. to live. Moderate positive correlations were found between indicators of dental caries: the number of children in the family greater than 3 and the material socially vulnerable status of the child’s family of origin. At the same time, the moderate negative correlation between the urban living environment of the children and the indicators of carious experience was estimated, which could be conventionally considered a moderate protection factor.

Therefore, in the present study it was found that dental caries damage bears the imprint of several socio-behavioral risk factors in the family environment. The study “Inequalities in the Republic of Moldova: Challenges and Opportunities, 2021” showed that families with three or more children are among the poorest categories of the population, and 8 out of 10 poor families with children live in rural areas. The risk for children in villages to be poor is 3 times higher than in those in cities. This study emphasizes that childhood poverty can have lifelong consequences, with the poorest children less likely to have access to health care or complete their education, and more likely to suffer from poor nutrition. Consequently, the considerable discrepancies between the poor and the rich population, between rural and urban areas, between women and men, young people and the elderly, continue to be other major obstacles to Moldova’s development [19].

The results obtained in this study are consistent with other studies conducted in the Republic of Moldova [14, 17] and Romania [11, 19-22], which established an increased incidence of dental caries in rural children compared to those in urban area. Several authors have highlighted the provision of dental care to children in rural areas or at an insufficient level and neglect of preventive measures, warns of the need to establish as soon as possible the treatment of caries, their complications and the application of methods to prevent dental disease [14, 17]. Several studies have shown that educational programs should be aimed at the general population: children, their parents, but also include the training of teachers in educational institutions, and family physicians who could contribute to awareness by parents in particular. of mothers, the role of predisposing factors in the appearance of dental caries [11-14, 17, 19-22].

Conclusions

1. As a result of the correlational analysis, a strong positive relationship was found between the indicators of tooth decay and the following socio-behavioral risk factors in the family environment: lack of parental verification of oral hygiene, mother’s level of education (incomplete higher education) and rural living environment. Moderate positive correlations were found between indicators of dental caries: the number of children in the family greater than 3 and the material socially vulnerable status of the child’s family of origin.
2. The identification of socio-behavioral factors of cariogenic risk in the family environment is relevant for the creation of health policies that address the needs of the population, including vulnerable population groups, with the establishment of a hierarchy of priority care and evaluation of sources allocated for the implementation of oral health programs, carrying out the treatment of dental diseases and implementing preventive measures.

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