Developing explanatory models of health inequalities in childhood dental caries.

OBJECTIVE: Long-term aim is to determine optimum interventions to reduce dental caries in children in disadvantaged communities and minimise the effects of exclusion from health care systems, of ethnic diversity, and health inequalities. DESIGN: Generation of initial explanatory models, study protocol and development of two standardised measures. First, to investigate how parental attitudes may impact on their children's oral health-related behaviours and second, to assess how dentists' attitudes may impact on the provision of dental care. SUBJECTS: Core research team, lead methodologists, 44 consortium members from 18 countries. To complete the development of the questionnaire, the initial set of items was administered to parents (n = 23) with children in nursery schools in Dundee, Scotland and sent to the same parents one week later. A standardised measure examining barriers to providing dental care for children aged 3 to 6 years was developed. 20 dentists working in primary dental care in Scotland completed the measure on two different occasions separated by one week. RESULTS: Explanatory models were developed. Family questionnaire: test-retest reliability excellent (r = 0.93 p < or = 0.001) with very good internal reliability (alpha = 0.89). Dentists questionnaire: excellent test-re-test reliability r = 0.88, (alpha = 0.90). CONCLUSIONS: Interaction between consortium members enhanced the validity of the questionnaires and protocols for different cultural locations. There were challenges in developing and delivering this multi-centre study. Experience gained will support the development of substantive trials and longitudinal studies to address the considerable international health disparity of childhood dental caries.

Familial and cultural perceptions and beliefs of oral hygiene and dietary practices among ethnically and socio-economicall diverse groups.

UNLABELLED: OBJECTIVE; The aim of this international study was to develop a valid and reliable psychometric measure to examine the extent to which parents' attitudes about engaging in twice-daily tooth brushing and controlling sugar snacking predict these respective behaviours in their children. A supplementary objective was to assess whether ethnic group, culture, level of deprivation or children's caries experience impact upon the relationships between oral health related behaviours, attitudes to these respective behaviours and to dental caries. CLINICAL SETTING: Nurseries, health centres and dental clinics in 17 countries. PARTICIPANTS: 2822 children aged 3 to 4 years and their parents. MAIN OUTCOME MEASURES: Dental examination of children and questionnaire to parents. RESULTS: Factor analysis identified 8 coherent attitudes towards toothbrushing, sugar snacking and childhood caries. Attitudes were significantly different in families from deprived and non-deprived backgrounds and in families of children with and without caries. Parents perception of their ability to control their children's toothbrushing and sugar snacking habits were the most significant predictor of whether or not favourable habits were reported. Some differences were found by site and ethnic group. CONCLUSIONS: This study supports the hypothesis that parental attitudes significantly impact on the establishment of habits favourable to oral health. An appreciation of the impact of cultural and ethnic diversity is important in understanding how parental attitudes to oral health vary. Further research should examine in a prospective intervention whether enhancing parenting skills is an effective route to preventing childhood caries.

A multi-country comparison of caries-associated microflora in demographically diverse children.

OBJECTIVE: The aim of this formative international collaborative research on childhood dental caries was to undertake an initial investigation comparing the dental plaque of young children from diverse ethnic and socioeconomic backgrounds with and without dental caries. BASIC RESEARCH DESIGN: The following four null hypotheses were investigated. There were no differences in numbers of individual taxa when comparing plaque samples from: 1) caries-free children from deprived and non-deprived backgrounds; 2) children from deprived and non-deprived backgrounds with at least 3 decayed teeth; 3) children from non-deprived backgrounds who are caries free with those from similar backgrounds with at least 3 decayed teeth; and, 4) children from deprived backgrounds who are caries free with those from similar backgrounds with at least 3 decayed teeth. PARTICIPANTS: 277 children aged 3-4 years from 5 countries. MAIN OUTCOME MEASURES: A sample of interproximal plaque from anterior teeth was collected using sterile dental floss, and cultured according to accepted international standards. RESULTS: Analysis of the data found that the first null hypothesis was accepted and that the fourth was rejected. Unexpectedly, the second null hypothesis was rejected as the children with caries from deprived and non-deprived backgrounds had a different caries-associated flora. In particular, children living in deprivation harbored more caries-associated bacteria [mutans streptococci and lactobacilli]. This greater microbial challenge was associated with a higher level of cavitated carious lesions and with more frequent consumption of confectionery. Conclusions Children from deprived backgrounds with caries may be further disadvantaged by having higher levels of caries-associated microflora.

Barriers to the treatment of childhood caries perceived by dentists working in different countries.

OBJECTIVE: To explore whether dentists' beliefs and attitudes to providing preventive and restorative dental care for young children can form a barrier to the provision of care. BASIC RESEARCH DESIGN: The Barriers to Childhood Caries Treatment (BaCCT) Questionnaire, a standardised international measure was developed and applied. PARTICIPANTS: Through a research consortium, each site was asked to recruit 100 dentists. The sample participating was not intended to be nationally representative. Dentists were mainly randomly selected and contacted by mail with one or more mailings depending on site. RESULTS: 2,333 dentists in 14 countries and 17 sites participated. Factor analysis identified four factors as potential barriers. Two factors were found to be barriers in many sites. First, in most countries, dentists agreed that young children's coping skills limit their ability to accept dental care. Secondly, dentists with negative personal feelings, for example, that providing care can be stressful and troublesome and that they feel time constrained. Differences in dentists' beliefs can be partly explained by their work profile, with those treating children often, and those working under systems where they feel they can provide quality care being least likely to identify barriers to providing care for children. CONCLUSIONS: The BaCCT Questionnaire was determined to be a valid psychometric measure. Separately, it was found that health systems do impact on dentists' ability to deliver preventive and restorative care for children but that these effects vary across countries and further work is needed to determine how best these should be examined.

International comparisons of health inequalities in childhood dental caries.

OBJECTIVE: To undertake formative studies investigating how the experience of dental caries in young children living in diverse settings relates to familial and cultural perceptions and beliefs, oral health-related behaviour and oral microflora. PARTICIPANTS: The scientific consortium came from 27 sites in 17 countries, each site followed a common protocol. Each aimed to recruit 100 families with children aged 3 or 4 years, half from deprived backgrounds, and within deprived and non-deprived groups, half to be "caries-free" and half to have at least 3 decayed teeth. OUTCOME MEASURES: Parents completed a questionnaire, developed using psychological models, on their beliefs, attitudes and behaviours related to their child's oral health. 10% of children had plaque sampled. RESULTS: 2,822 children and families were recruited. In multivariate analyses, reported toothbrushing behaviours that doubled the odds of being caries-free were a combination of brushing before age 1, brushing twice a day and adult involvement in brushing. Analyses combining beliefs, attitudes and behaviours found that parents' perceived ability to implement regular toothbrushing into their child's daily routine was the most important predictor of whether children had caries and this factor persisted in children from disadvantaged communities. 90% of children with lactobacillus had caries. CONCLUSIONS: Parental beliefs and attitudes play a key role in moderating oral health related behaviour in young children and in determining whether they develop caries. Further research is indicated to determine whether supporting the development of parenting skills would reduce dental caries in children from disadvantaged communities independent of ethnic origin.