Parents’ and Caregivers’ Knowledge and Perception towards the use of Fluoridated Toothpaste in Children

Haifa AlAmro^1,2*, Meshal Alwadi¹, Khalid Alrehaili¹, Ali Alotaibi¹, Rayan Alkadi¹, Abdulaziz Alomran¹ and Abdullah Alhussain¹

^*Correspondence: Haifa AlAmro, Department of Preventive Dental Science, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia, Email:

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Introduction

Caries is known to be one of the most common prevalent diseases worldwide. It is costly to society, but the cost of childhood caries goes beyond the cost of direct healthcare; it includes the social cost of pain, adverse effects on cognitive development, increased school absenteeism, increased caregiver absenteeism from work, and lower oral health-related quality of life [1].

The prevalence of caries in school-age children in Saudi Arabia is estimated to be 80% in primary dentition and 70% in permanent dentition [2]. According to a meta-analysis of more than 70 randomized or quasirandomized controlled clinical trials, fluoridated toothpastes are effective in lowering the prevalence of dental caries in permanent teeth, with the effect increasing in children with a higher baseline level of caries and a more significant concentration of fluoride in the toothpaste, greater frequency of use, and supervision of brushing [3,4]. A meta-analysis of eight clinical trials on caries increment in preschool children also shows that tooth brushing with fluoridated toothpaste significantly reduces dental caries prevalence in primary dentition [5]. Using no more than a smear or rice-size amount of fluoridated toothpaste for children less than three years of age may decrease the risk of fluorosis. Using no more than a pea-size amount of fluoridated toothpaste is appropriate for children aged three to six [6]. To maximize the beneficial effect of fluoride in toothpaste, brushing should be done twice a day under supervision, and rinsing after brushing should be reduced or eliminated [7].

A recent study conducted in Chicago showed that approximately 41% of children brushed once a day or less, and 19% of caregivers did not regularly assist. Almost all children used toothpaste (96%), but 36% of caregivers did not know if it contained fluoride [8]. Higher percentages were reported in a study in Poland where 90.2% of the parents were not aware of the fluoride concentration in their children’s toothpaste [9]. Another study by Bennadi et al. demonstrated that 72% of caregivers allow their children to use toothpaste for adults containing 1450 ppm, regardless of their age [10]. As for studies in Saudi Arabia, one has shown that the majority of the parents were not able to correctly report whether the toothpaste their children used was fluoridated or non-fluoridated [11].

Parents and caregivers have a significant role in the child's oral health and hygiene, and their oral health knowledge and attitude have a significant impact on their children. Insufficient parental knowledge will result in undesirable consequences, and it will affect their children's attitude toward oral health negatively. It has been reported that children whose parents lack awareness and knowledge of oral health have a higher chance to have dental caries [12].

There is limited data among the Saudi population on the knowledge of parents and caregivers on the type of toothpaste their children use, the amount of toothpaste dispensed, and the necessity for supervised tooth brushing. This study assessed the parents’ and caregivers’ knowledge and perception regarding the use of fluoridated toothpaste in children, the amount of toothpaste applied, and the need for supervised tooth brushing gathered from a sample of children under the age of thirteen years old from different communities in Riyadh, Saudi Arabia.

Materials and Methods

Study design

This is a cross-sectional study of parents and caregivers of pediatric patients 12 years old and younger attending governmental and private hospitals including King Abdullah Specialized Children’s Hospital (KASCH), dental clinics at King Saud bin Abdulaziz University for Health Sciences (KSAUHS), and private dental clinics. The study was approved by the Internal Review Board (IRB) committee at King Abdullah International Medical Research Center (KAIMRC), Saudi Arabia (SP21R/360/06). Surveys were conducted between June 2021 and November 2021 in Riyadh, Saudi Arabia.

Inclusion and exclusion criteria

A self-developed questionnaire was validated before the commencement of the study and consents were obtained from parents/caregivers who fit the inclusion criteria. The following inclusion criteria were established: a healthy child who is 12 years old or younger, a parent or a caregiver who is at least 18 years old, and familiar with the child’s oral hygiene practices. Parents and patients who did not meet the inclusion criteria or refused to participate were excluded.

Sample size and data collection

The questionnaires were self-distributed and consisted of 18 items related to demographics, location of data collection, the main criterion for choosing the toothpaste, frequency of toothbrushing, amount of toothpaste used, the concentration of fluoridated toothpaste, and caregiver’s supervision. The amount of toothpaste dispensed was presented to the participants through pictures (smear, pea-size, half-load, and fullload) (Figure 1).

Figure 1: Amount of dispensed toothpaste: (a) Smear; (b) Pea-size; (c) Half-load; (d) Full-load.

The estimated sample size was calculated to be 385. Participants were involved through a convenient sampling technique.

Statistical analysis

Data analysis was performed using Statistical Package for the Social Sciences (SPSS) 23rd version. Frequency and percentages were used to display categorical variables. Minimum, maximum, mean, and standard deviation were used to display numerical variables. Independent t-test and ANOVA test were used to test for factors associated with participants’ knowledge (type of toothpaste, the use of fluoridated toothpaste, fluoride concentration in the toothpaste, frequency of brushing, post-brushing behavior) and perception (main criterion for toothpaste selection, parent’s involvement in toothbrushing, type of involvement). Knowledge and perception scores for each participant were calculated based on their answers to the questions: high level if the score was more than 75% of the total score, moderate if the score is between 50-75%, and low if it is less than 50%. The participants’ knowledge and perception were further analyzed and associated with the relationship to the child, the age of the caregiver, the caregiver’s educational level, the child’s gender and age, location of data collection, knowledge level, and perception level. ANOVA test was followed by Tukey post-hoc test to determine where the exact difference between groups exists. The level of significance was set at 0.05.

Results

A total of 388 participants were included in the study. The demographic characteristics of survey respondents and their children are described in Table 1. One hundred eighty-five (47.7%) of the participants were recruited from King Abdullah Specialist Children’s Hospital, 89 (22.9%) were recruited from the college of dentistry at King Saud bin Abdulaziz University for Health Sciences, and 114 (29.4%) were recruited from private dental clinics.

Table 1: Demographic profile of the participants (n=388).

Participants’ perception and knowledge level

The assessment of participants' perception of the use of fluoridated toothpaste in children is shown in Table 2. The participants' minimum score was 0, the maximum was 5, and the mean was 1.6 ± 1.09 (SD). Only 8.8% chose fluoride concentration as their main criterion for selecting the child's toothpaste, whereas 43.3% of the participants based their choice on the brand. When the participants were asked about their involvement in the children’s toothbrushing, 42% never got involved, 13% brush their children's teeth by themselves, and only 4.9% check their child's teeth after brushing. A low perception level was seen in 79.6% of the participants, 11.1% had a moderate perception level, and only 9.3% had a high perception level.

Table 2: Assessment of participants’ perception of the use of fluoridated toothpaste in children (n=388).

The assessment of participant knowledge of the use of fluoridated toothpaste in children is illustrated in Table 3. The participants’ minimum score was 0, the maximum was 6, and the mean was 2.9 ± 1.2 (SD). Fifty seven percent of the parents reported that their children were using children’s toothpaste, 51% were unsure whether the toothpaste was fluoridated or not, and 87% were unaware of the fluoride concentration in the used toothpaste. When the participants were asked about the child’s oral hygiene practices, 32.5% reported brushing twice a day, 31.4% brushes once a day, and 85.8% reported rinsing with water after toothbrushing. Almost 70% of the participants had a low knowledge level, 29% had a moderate knowledge level, and only 1% had a high knowledge level.

Table 3: Assessment of participants’ knowledge of the use of fluoridated toothpaste in children.

Factors associated with knowledge and perception

Different variables were associated with the participants’ knowledge and perception of the use of fluoridated toothpaste in children (Table 4). Relationship to the child showed a significant difference where mothers had a higher knowledge and perception score compared to fathers; other caregivers (siblings, grandparents, and uncles/aunts) were excluded since they only compromised 3.7% of the total number of the study participants. The age of the caregiver was only significantly associated with the perception; those aged between 21 – 30 years had a significantly higher perception score compared to older participants. Participants’ educational level was significantly associated with the knowledge and perception scores; the higher the educational level, the higher the score.

Table 4: Factors associated with knowledge and perception of the use of fluoridated toothpaste in children.

The child’s gender and age were significantly associated with both scores; participants with female children had significantly higher knowledge and perception scores compared to those with male children. The overall perception level was also significantly associated with the knowledge score where it was observed that the higher the perception level, the higher the knowledge score (P= 0.009).

Participants’ involvement and amount of toothpaste used across different children’s age groups

There was a difference in participants’ involvement in their children’s teeth brushing (Table 5). In children less than 3 years of age, only 43.8% of the participants were always involved in their children’s toothbrushing and 34.4% were never involved. Of those who were involved, 71.4% brushed their children’s teeth by themselves, and the remaining participants were involved either by watching or reminding their children to brush. For children between the age of 3 and 6, 26.8% of the participants were never involved, and 31.8% were always involved with the majority reminding their children to brush. As for the participants with children who are 7-12 years of age, 58.8% were never involved in their children’s toothbrushing, and of those who were involved, 61.6% reminded their children to brush. Different amounts of toothpaste used were linked to different age groups. Only 21.9% of children younger than 3 years old were using the correct amount (smear), whereas 37.5% of the participants were dispensing a pea-sized amount, 15.6% dispensing an amount of a half load, 9.4% dispensing a full load, and 15.6% were unsure of the amount dispensed. For children 3-6 years old, 46.4% of the participants dispensed the recommended amount (pea-size) and 38.5% dispensed an amount equal to a half load. Forty-six percent of participants with children between the ages of 7-12 had reported dispensing a half load amount of toothpaste, 26% had dispensed a pea-sized amount, and almost 10% were not aware of the exact amount.

Table 5: The difference in participants’ involvement and amount of toothpaste used across different children’s age groups.

Discussion

The primary aim of this study was to assess the knowledge and perception of parents and caregivers regarding their children’s oral health for those who are residing in Riyadh, Saudi Arabia. Parents have a significant role in their children’s oral hygiene practices and attitudes and thus they should be instructed to perform proper dental care for their children. Children’s oral health will ultimately be affected by parents’ low level of oral health awareness. The lack of parental knowledge on the amount of toothpaste to use and on the proper fluoride concentration seems to be a common problem [13,14]. Therefore, parental education on oral health plays a crucial role in caries prevention in preschool children and it has been proven to be effective in reducing the incidence of caries [15-18].

Fluoridated toothpaste

Although a high percentage of participants (77.1%) have heard about fluoride in toothpaste, 51% were unsure whether the child’s toothpaste contained fluoride or not. Findings from another study conducted in Riyadh showed that 51.2% of the participants provided fluoridated toothpaste, but 36.7% do not know if the toothpaste used by their children contained fluoride [19]. One of the limitations of this study is the possibility of inaccurate self-reporting of the toothpaste used. Data from Alshehri, et al. suggested that self-reported use of fluoridated toothpaste was low (29.2%) in comparison to the actual type (55.9%) based on the information obtained from the manufacturers [11]. Participants’ use of fluoridated toothpaste in the present study is low (35.3%) which is similar to Alshehri, et al. findings (29.2%), but much lower than the findings reported by Aventti, et al. (50.4%) and Opydo-Szymaczek, et al. (93%) [11,8,20]. Such findings mandate the incorporation of oral hygiene instructions including the type of toothpaste that is recommended for each age group.

Fluoride concentration

Fluoride toothpaste with 1,000 parts per million or more reduces dental cavities in both the permanent and primary dentition, according to evidence of moderate to high certainty [4]. Eighty-seven percent of the participants did not know the exact concentration of fluoride in the toothpaste. This suggests that they have limited knowledge about fluoride and thus interventions are needed to further educate them about the current guidelines and recommendations for the use of fluoridated toothpaste for optimum caries prevention and minimizing the risk of fluorosis. When participants were asked about the type of toothpaste, 57% reported the use of children’s toothpaste, 35% were using adult toothpaste, and the remaining was unsure. Findings from Bennadi, et al. showed a higher percentage (72%) of participants using adult toothpaste for preschool children in contrast to Elkarmi, et al. where 82.5% reported using children’s toothpaste [10,21]. Parental education is essential to ensure proper toothpaste selection.

Amount of toothpaste

Recommendations had been established concerning the amount of toothpaste to be dispensed; a smear or a rice-sized amount of fluoridated toothpaste for children under the age of 3 and a pea-sized amount of fluoridated toothpaste is appropriate for children between 3 and 6 years old [6]. Avenetti, et al. reported that 32.8% of children less than 3 years old used pea size, and 55.7% used smear size [8]. Another study in Poland reported that children aged 4 to 7 years old used a smear to pea-sized amount in 60% of the participants, with the remaining using half load to full load quantity [20]. In contrast, data from the present study showed that only 21.9% of children less than 3 years old and 46.4% of children between the age of 3-6 years old used the recommended amount of toothpaste. These results may indicate the misconception parents have regarding the amount of toothpaste that is required for the anti-caries effect. Anticipatory guidance and oral health promotion programs will further educate the community regarding the best clinical recommendations.

Parental supervision

Evidence-based reviews show that fluoridated toothpaste reduces dental caries in children; the benefit is stronger in children with higher baseline caries levels, higher fluoride concentrations in the toothpaste, more frequent usage, and supervision [3,4]. Although parental supervision is crucial, especially to young children, only 43.8% of the participants with children less than 3 years of age are always involved in their children’s brushing, whereas 34.4% never get involved. For children between the ages of 3 and 6, an almost equal number of participants were either always or sometimes involved, 31.8% and 30.2% respectively. For older children aged from 7-12 years old, less involvement has been reported with almost 59% being never involved. Avenetti, et al. reported that only 19% of caregivers had someone help the children brush only sometimes or not at all, whereas Bennadi, et al. reported that 83% of preschool children were not supervised which comes in agreement with Elkarmi et al. where 78% of the parents did not brush their children’s teeth by themselves [8,10,21]. Young children lack the needed manual dexterity required for proper brushing and their inability to completely expectorate the toothpaste, hence supervised toothbrushing is necessary.

Tooth brushing frequency

Children brushing their teeth twice daily with fluoridated toothpaste and oral hygiene instructions are the keystone for the caries prevention program [22]. The frequency of teeth brushing has played a crucial role in decreasing caries. A study conducted in Riyadh, Saudi Arabia by Alyousef et al. stated that 54.5% of the children brushed their teeth once, and 45.5% brushed twice [23]. In contrast to the present study, only 32.5% of the participants reported brushing twice a day and 31.4% once. Based on experts’ opinions and recommendations to ensure the highest fluoride intake and efficacy, children should minimize rinsing with water after brushing [22]. Binahmed, et al. reported that 79% of caregivers think that a child should rinse their mouth after brushing [24]. Findings from this study showed that the majority of participants (85.8%) rinsed with water after brushing, similar to the findings reported by Bennadi, et al. (84%) [10].

Knowledge and perception level

The relationship between knowledge and perception with caregivers’ educational level was found to be statistically significant. Similarly, a study in Italy reported that children of mothers with low educational levels showed a high prevalence of caries (87.2%) in contrast to those with higher educational levels (55.4%) [25]. Chen et al. stated that parents with higher educational levels had greater oral health awareness than other parents, and their children displayed better dental hygiene habits, which is in agreement with the findings of this study [26].

The data also shows that mothers are significantly higher in knowledge and perception scores compared to fathers which are in contrast to Alshehri, et al. findings [11]. The overall knowledge score was low (69.7%) among caregivers in the present study with similar findings to Alshehri et al. [11]. The location of data collection and knowledge score showed statistically significant results. Higher knowledge scores were observed from participants attending the college of dentistry compared to participants at private dental clinics and King Abdullah Specialist Children’s Hospital. More emphasis should be directed towards providing an oral health education component not just during the dental visits but also during the child’s well visits with their pediatrician or medical provider.

Conclusion

Findings in the present study suggest that there is a lack of awareness of proper guidelines for the selection and usage of toothpastes in children. Parents should be motivated to supervise and assist their children’s brushing using the proper toothpaste appropriate for their age. The level of parental awareness is highly associated with their offspring’s quality of life in different aspects including oral health. More emphasis should be placed on increasing parental attitude and knowledge, which will positively reflect on their children's oral health status.

References

1. Casamassimo PS, Thikkurissy S, Edelstein BL, et al. Beyond the dmft: the human and economic cost of early childhood caries. J Am Dent Assoc 2009; 140:650-657.

Indexed at, Google Scholar, Cross Ref

2. Al Agili DE. A systematic review of population-based dental caries studies among children in Saudi Arabia. Saudi Dent J 2013; 25:3-11.

Indexed at, Google Scholar, Cross Ref

3. Marinho VC, Higgins J, Logan S, et al. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003.

Indexed at, Google Scholar, Cross Ref

4. Walsh T, Worthington HV, Glenny AM, et al. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database Syst Rev 2019.

Indexed at, Google Scholar, Cross Ref

5. Dos Santos AP, Nadanovsky P, de Oliveira BH. A systematic review and meta‐analysis of the effects of fluoride toothpastes on the prevention of dental caries in the primary dentition of preschool children. Community Dent Oral Epidemiol 2013; 41:1.

Indexed at, Google Scholar, Cross Ref

6. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste efficacy and safety in children younger than 6 years: A systematic review. J Am Dent Assoc 2014; 145:182-189.

Indexed at, Google Scholar, Cross Ref

7. http://www.sign.ac.uk
8. Avenetti D, Lee HH, Pugach O, et al. Tooth brushing behaviors and fluoridated toothpaste use among children younger than three years old in Chicago. J Dent Child 2020; 87:31-38.

Indexed at, Google Scholar

9. Turska-Szybka A, Świątkowska M, Walczak M, et al. What do parents know about the use of fluoride products in children? A questionnaire study. Fluoride 2018; 51:114-121.

Indexed at, Google Scholar, Cross Ref

10. Bennadi D, Kshetrimayum N, Sibyl S, et al. Toothpaste utilization profiles among preschool children. J Clin Diagn Res 2014; 8:212.

Indexed at, Google Scholar, Cross Ref

11. Alshehri M, Kujan O. Parental views on fluoride tooth brushing and its impact on oral health: A cross-sectional study. J Int Soc Prevent Community Dent 2015; 5:451.

Indexed at, Google Scholar, Cross Ref

12. Vanagas G, Milašauskienė Ž, Grabauskas V, et al. Associations between parental skills and their attitudes toward importance to develop good oral hygiene skills in their children. Medicina 2009; 45:718.

Indexed at, Google Scholar

13. Poutanen R, Lahti S, Tolvanen M, et al. Parental influence on children's oral health-related behavior. Acta Odontol Scand 2006; 64:286-292.

Indexed at, Google Scholar, Cross Ref

14. Lima CV, Pierote JJ, de Santana N, et al. Caries, toothbrushing habits, and fluoride intake from toothpaste by Brazilian children according to socioeconomic status. Pediatr Dent 2016; 38:305-310.

Indexed at, Google Scholar

15. Rong WS, Bian JY, Wang WJ, et al. Effectiveness of an oral health education and caries prevention program in kindergartens in China. Community Dent Oral Epidemiol 2003; 31:412-416.

Indexed at, Google Scholar, Cross Ref

16. Harrison R, Benton T, Everson-Stewart S, et al. Effect of motivational interviewing on rates of early childhood caries: A randomized trial. Pediatr Dent 2007; 29:16-22.

Indexed at, Google Scholar

17. Tinanoff N, Reisine S. Update on early childhood caries since the surgeon general's report. Acad Pediatr 2009; 9:396-403.

Indexed at, Google Scholar, Cross Ref

18. Kulkarni GV. Long-term effectiveness of parent education using the “baby oral health” model on the improvement of oral health of young children. Int J Dent 2013; 2013.

Indexed at, Google Scholar, Cross Ref

19. Salama F, Alwohaibi A, Alabdullatif A, et al. Knowledge, behaviours and beliefs of parents regarding the oral health of their children. Eur J Paediatr Dent 2020; 21:103-109.

Indexed at, Google Scholar, Cross Ref

20. Opydo-Szymaczek J, Ogińska M, Wyrwas B. Fluoride exposure and factors affecting dental caries in preschool children living in two areas with different natural levels of fluorides. J Trace Elem Med Biol 2021; 65:126726.

Indexed at, Google Scholar, Cross Ref

21. ElKarmi R, Shore E, O’Connell A. Knowledge and behaviour of parents in relation to the oral and dental health of children aged 4–6 years. Eur Arch Paediatr Dent 2015; 16:199-204.

Indexed at, Google Scholar, Cross Ref

22. Toumba KJ, Twetman S, Splieth C, et al. Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document. Eur Arch Paediatr Dent 2019; 20:507-516.

Indexed at, Google Scholar, Cross Ref

23. Alyousef AM, Almehrej BA, Alshahrani MA, et al. Arabian parents knowledge, attitude, and practice towards their childrens oral health and early childhood caries resided in Riyadh province: An online-based cross-sectional survey. Ann Med Health Sci Res 2021.

Google Scholar

24. Abullais SS, Al-Shahrani FM, Al-Gafel KM, et al. The knowledge, attitude and practices of the caregivers about oral health care, at centers for intellectually disabled, in Southern Region of Saudi Arabia. Healthcare 2020; 8:416.

Indexed at, Google Scholar, Cross Ref

25. Cianetti S, Lombardo G, Lupatelli E, et al. Dental caries, parents educational level, family income and dental service attendance among children in Italy. Eur J Paediatr Dent 2017; 18:15-18.

Indexed at, Google Scholar, Cross Ref

26. Chen L, Hong J, Xiong D, et al. Are parents’ education levels associated with either their oral health knowledge or their children’s oral health behaviors? A survey of 8446 families in Wuhan. BMC Oral Health 2020; 20:10.

Indexed at, Google Scholar, Cross Ref