VISUOMEN Ė S SVEIKATA Associations between parental skills and their attitudes toward importance to develop good oral hygiene skills in their children

Summary. Background. For many years, poor oral hygiene and frequent consumption of sugars is known as key behavioral risk factors for oral diseases, such as dental caries and periodontal disease. Parental attitudes toward children’s oral health could be associated with their own oral health skills. We aimed to analyze associations between parental skills and attitudes toward caries development and possibilities to control positive oral health behavior in their children. Material and methods. A cross-sectional study involved 550 parents of 3-to 4-year-old children. A 40-item questionnaire was developed from the Theory of Planned Behavior, Health Belief Model and the Health Locus of Control model, and parental attitudes toward dental caries in their children were analyzed. Results. A total of 397 filled-in questionnaires were collected; the response rate was 72%. Parents


Introduction
Poor oral hygiene and frequent consumption of sugars is known for many years as key behavioral risk factors for oral diseases, such as dental caries and periodontal disease (1)(2)(3)(4).Dental caries occur because of demineralization of enamel and dentine by organic acids produced by bacteria in dental plaque through the metabolism of sugars derived from diet (4)(5)(6).Dental caries also affects preschool age children's growth and well-being (7,8).Behaviors adopted by individuals can make a negative or positive contribution to health.Parental knowledge and attitudes toward oral health can promote appropriate oral hygiene skills in their children (3,(9)(10)(11)(12).There is evidence that good parental knowledge and oral hygiene positively affects children's dental health (13)(14)(15)(16)(17)(18).Toothbrushing less than twice daily and sugar snacking between meals have been identified as key behavioral factors explaining the presence of dental caries in children (2,9,19).
Children are more likely to be caries free if their teeth are brushed from an early age, twice daily with fluoride toothpaste, with parental involvement and in an environment in which the frequency of sugar intake is controlled (19,20).In contrast to this parenting skills approach, health education models have dominated in the majority of caries prevention strategies (21).However, the evidence that this has been an effective approach is not strong (22,23).Parental attitudes toward caries development and prevention are likely to predict positive behavior of twice-daily toothbrushing.Since this is the main factor that health education is likely to influence, the value of a purely educative approach continues to be questionable in achieving behavior change.However, findings consistently demonstrated that parents' self-belief (parental efficacy) to ensure twice-daily toothbrushing and control sugar snacking in their children was predictive of toothbrushing and sugar snacking behavior, but we are still lacking an evidence for association between parental skills and attitudes in the development of good oral hygiene skills in children.
The aim of this study was to analyze associations between parental oral hygiene skills and attitudes toward the importance of developement of good oral hygiene skills in their children.

Study design
A cross-sectional study design was used.

Sample size
Sample size was calculated using EpiInfo 2000 Statcalc software, and sample represented Kaunas region population (Lithuania).Previous studies showed a response rate of 67% (12,14,16).Therefore, it was decided to distribute the questionnaires to 550 parents.In total, we collected 397 filled-in questionnaires; the response rate was 72%.

Questionnaire
The questionnaire consisted of 40 items concerning parental and their children's oral health behaviors that was developed from the Theory of Planned Behavior (24), Health Belief Model (25), and the Health Locus of Control (26-28) model, and parental attitudes toward dental caries in their children (9) were also included seeking to investigate how parental attitudes may impact their children's behaviors.Parental skills were assessed according to answers on own oral hygiene skills regarding the use of an appropriate toothbrush, toothbrushing twice a day or more often, use of sugar snacks, and frequency of visits to oral hygienists.

Data collection and statistical analysis
The data were collected through the questionnaires filled in by the parents of 3-4-year-old children.The data were computed-coded and analyzed using the Statistical Package for the Social Sciences for Windows, version 10.0 (SPSS Inc).Pearson's χ 2 test was used for evaluation of the statistical significance at the P<0.05 level.All answers were summarized by giving equal weight for each of the correct answers.The mean values were used to define groups of comparison, and then the groups were compared by perental oral hygiene skills and attitudes toward children's oral health.
The factors included into the final model were previously assessed for reliability (Table 1).The data on sociodemographic characteristics of respondents and their oral health behaviors were additionally collected.

Results
Of the 397 respondents, 320 (80.4%) were females and 77 (19.6%) were male.The age ranged from 21 to 65 years (mean age, 33.1±6.94years).Average household incomes per capita in families with selfreported good and poor parental oral hygiene skills were 511.65±270.21Lt and 466.71±263.11Lt, respectively.The mean number of children in families with good and poor parental oral hygiene skills was 1.56±0.6 and 1.59±0.7 children per family, respectively.All other descriptive characteristics are shown in Table 2.
Regarding parental skills in own oral hygiene, our study showed that more than half (52.6%) of the parents use an appropriate toothbrush.Altogether, 69.7% of the parents were brushing their teeth twice a day or more often as it is recommended.Most of parents (77.7%) reported inappropriate use of sugar snacks.Study results highlighted that most of the parents Parental skills and attitudes oral hygiene in childhood (71.5%) had visited an oral hygienist at least once during the last year.Using Pearson's test, associations between parental attitudes toward tooth decay in their children and own oral hygiene skills were analyzed (Table 3).Parents with good own oral hygiene skills significantly more often understood the importance of brushing their children's teeth (χ 2 =29.8; df=1; P<0.001).Study results also highlighted significant differences in importance to prevent tooth decay (χ 2 =3.1; df=1; P=0.051), importance to control child sugar snacking (χ 2 =10.6; df=1; P=0.001), and parental perceived seriousness of tooth Giedrius Vanagas, Žemyna Milašauskienė, Vilius Grabauskas, Aušra Mickevičienė decay in children (χ 2 =9.2; df=1; P=0.002) comparing the parents with poor and good oral hygiene skills.Parental efficacy to control proper toothbrushing and parental efficacy to control sugar snacking in children was higher in the group of parents with good oral hygiene skills; however, the differences were not significant.

Discussion
This study showed that more than half of the parents reported appropriate own oral hygiene skills; 52.6% of the parents use an appropriate toothbrush.Altogether, 69.7% of the parents were brushing their teeth twice a day or more often as it is recommended.According to parental habits, our study results are in accordance to earlier study on Lithuanian population (20), which showed that half of the parents brush their teeth irregularly and only 14% of the parents brushed their children's teeth.However, 12.0% of the parents refuse to include their children in preventive program on dental caries without known reasons.Our study revealed that parental attitudes toward their children's oral health were significantly associated with positive parental oral health behavior.According to this, parental attitudes toward oral health should be considered an essential factor influencing the development of positive health-related behavior in children.Oral diseases are clearly related to the behavior, and it is expected that the prevalence of dental caries and periodontal disease would decrease with the improvements in attitudes and oral hygiene skills.This also could have an influence on decreasing the prevalence of dental caries in child teeth (29).The most common and effective way to promote children's oral hygiene is parental supervision and development of child skills for regular toothbrushing together with parental control of sugar consumption; therefore, brushing is recommended to be adopted as a habit, which should be repeated every morning and evening, at least twice a day.Earlier studies demonstrated a high correlation between the frequency of toothbrushing and OHI-S (by Green-Vermillion) index (30).Therefore, special emphasis on parental own attitudes, skills, and knowledge of why and how often toothbrushing should occur and why sugar should be controlled should be placed in the development of healthy lifestyle behaviors in their children.When parents improve their oral hygiene skills by themselves, their children accept this healthy behavior more easily.It is hypothesized that people who have assimilated healthy behavior and feel a sense of personal control over their oral health are more likely to have positive attitudes and adopt proper selfcare practices in their relatives (29,31).With our study, we can confirm these hypotheses by discovering significant associations between parental own oral hygiene skills and attitudes.This study proposed evaluation criterions based on theoretical models developed from the Theory of Planned Behavior (24), Health Belief Model (25), and the Health Locus of Control (26-28) model for evaluation of parental own oral hygiene skills and attitudes such as understood importance to brush child teeth, importance to prevent tooth decay, importance to control child sugar snacking, and perceived seriousness of tooth decay in children.
Methodological strengths of the present study include the sufficient sample size, methodological background, and availability of comparable survey instruments.This study design, although scientifically less rigorous than the longitudinal studies, is less time and resource consuming.In the present study, data were gathered at one point in time from the same population, but not from the same household individuals.Lack of information about non-respondents precludes any conclusion about a possible selection bias, although the response rates seem to be high enough to ensure that the target population is reflected with a reasonable degree of accuracy (32).
Further research is needed to evaluate in prospective studies whether parental attitudes is more favorable in establishment and maintenance of positive oral health behaviors in children.Furthermore, it would be an advantage to repeat a cross-sectional survey, with the same target population and sampling frame, as it is the most appropriate and straightforward design for providing a series of survey estimates by which changes in a population can be monitored over periods of time (32,33).Trend studies of oral health-related behaviors, using a repeat cross-sectional design, have previously been reported in testing the changes in oral health and lifestyle (34).

Conclusions
More than half (61%) of the parents reported appropriate own oral hygiene skills.Parental attitudes toward children's oral health were significantly associated with their own oral health behavior and understanding the importance of development of oral hygiene skills in their children.