The results of this study show that the group of participating parents lack basic child related oral health knowledge. The results are consistent with findings from countries around the world conducting similar research (AlYahya 2016; Niadu and Nunn 2020).
The response rate is high (91.4%) indicating that parents are willing to participate in research and enthusiastic about improving their knowledge. Most caregivers accompanying children to their healthcare visits are mothers (74.9%). The majority of mothers in Jordan (86%) were never employed making most of them housewives responsible for most educational and medical issues of their children (Department of statistics (2018)).
The average knowledge score is 6.4 out of 20 which is very low and not even close to a passing score. Parents’ knowledge is poor in most aspects of child related oral health; for example, only 11.7% of parents know that a child’s first dental visit should be around his/her first birthday and a similar percentage know that tooth brushing should start with the eruption of the first tooth (Public Health England 2014). Although 67.8% of parents realize that children’s teeth should be brushed twice a day, only half are aware that night-time is the best time for toothbrushing (http://www.AAPD.org/policies). Surprisingly, only 28.4% of parents recognize that tooth brushing should be supervised up to at least 7 years of age and most parents think that their children can efficiently brush on their own from about 3 years of age. Only 20.5% of participants are aware of fluoride varnish and its well-established role in caries prevention (Marinho et al., 2009). Parental knowledge regarding anticariogenic dietary practices is not better. Only 18.4% of parents recognize that 3-4 sugar intakes per day is ideal. Most parents believe that 1-2 sugar containing foods or drinks per day is ideal. This result might be affected by social desirability bias where participants will answer questions in a way they think will be favored by others. What is even worse is that only a few parents (15.6%) understand that the best time to have a sugar containing snack is after a main meal and fewer parents (7.2%) believe that sugary foods/drinks should be consumed at once. Most parents think that sugar containing foods/drinks should be divided into portions and consumed over the day and between meals. It is well known that frequent in-between meal consumption of sugar-added snacks or drinks (e.g., juice, formula, soda) increase the risk of caries (Tinanoff and Palmer 2000). Avoiding frequent consumption of juice or other sugar-containing drinks and limiting cariogenic foods to mealtimes are among the recommendation for preschool children based on the principles of cariology (Tinanoff and Palmer 2000). Only 33.8% of parents think that bottle feeding should stop between 12 and 18 months of age. The majority believe that children can safely continue bottle feeding, even at night, until 3 years of age. Moreover, only 21.5% of parents believe that breast milk contains sugar, and around a quarter understand that consuming milk throughout the night or consuming fresh juice from a bottle are cariogenic behaviors. It is well documented that bottle feeding at night, frequent bottle feeding during the day, and late weaning can lead to caries (Harris et al., 2004).
Regarding dental development, a little more than half (56.3%) know that the first primary tooth erupts at around 6 months of age. This percentage drops to (32.7%) when it comes to the eruption time of the first permanent tooth. Unfortunately, only 19.9% of parents understand that not all permanent teeth are preceded by primary teeth. This combined with the poor knowledge of the eruption time of the first permanent tooth explains the high percentage of caries seen in first permanent molars in 7- 8-year-old children (Al Dossary et al., 2018). Parents are usually surprised that their child has caries in a permanent molar when they are sure that no primary molar has exfoliated before. Improving parental knowledge in this regard is very important to help prevent caries in newly erupting first permanent molars.
Parental attitudes towards child’s oral heath are generally unfavorable. Around 60% of parents believe that regular tooth brushing prevents caries. Half think that regular dental visits can prevent caries and only 31% agree that primary teeth are important to the child.
Dental visits for treatment of caries are likely to be a stressful experience to children and their parents as dental fear and anxiety are common among children and adolescent and is related to pain (Shim et al., 2015). To help children get through those visits successfully and achieve the desired outcome, parents sometimes use rewards. As a reward, more than half (58.3%) of parents in this study report giving their children a sugar containing snack. Although 79% and 65.2% of parents realize that chocolate and fizzy drinks contain sugar respectively, only 30.4% are aware of the cariogenic potential of biscuits. A little more than half (54%) think that artificial juice has sugar and only 5.6% recognize that fresh juice has sugar. Between meals, most parents (93.8%) report giving their children either confectionery, juice, or chips when they ask for something to eat. As an alternative, 54.7% of parents would give fruits and 33.8% would offer vegetables, while only a few (11.5%) would offer popcorn. It is very important that parents understand the importance of non-sugar containing snacks between meals and that the consumption of any sugar containing food/drink should ideally be within or immediately after a meal (Tinanoff and Palmer 2000).
Parental knowledge on prevention of caries in children significantly improved after reading the leaflet indicating the success of the used leaflet in delivering the intended educational messages. The difference in parental knowledge was not statistically significant in the knowledge of the frequency of tooth brushing or the amount of toothpaste used for a 3-year-old or younger. The percentage of parents with correct knowledge regarding the frequency of toothbrushing before reading the leaflet was high (78.1%) possibly again due to social desirability bias. Unfortunately, this does not necessarily reflect their behavior. Similarly, the percentage of parents with correct knowledge regarding the amount of toothpaste to be used for a child aged 3 or younger was high before reading the leaflet and improved slightly after reading the leaflet. This could be explained by the fact that most parents know that younger children are unable to spit and are afraid that they will swallow the toothpaste. Therefore, they correctly chose the least amount of toothpaste (Wright et al., 2014). Although the difference in parental knowledge before and after reading the leaflet was statistically significant, the percentage of parents with correct knowledge after the leaflet intervention was still less than 50% in some aspects including, knowledge of the age at the first dental visit, knowledge of the time to start brushing, knowledge of the best time to eat sugar containing snacks, and knowledge of whether sugar containing food is best consumed at once or divided. This means that important messages on caries prevention in children should be delivered by other means in addition to educational leaflets.
The relatively limited number of pediatric dentists available to deliver face to face child related oral health education combined by the low number of patients attending the pediatric dentist regularly makes it necessary to find other means of nationwide education. Moreover, general dental practitioners in Jordan demonstrated poor knowledge in terms of delivering caries preventive advice (AlJafari et al., 2021). Medical students in Jordan showed poor knowledge on caries prevention in children as well (Sonbol et al., 2020); which means that medical doctors are not likely to be part of oral health education, at least for the time being. Leaflets are a relatively cheap and easily accessible method of education. Having friendly, easy to read leaflets readily available in waiting rooms in all healthcare centers for children and adults to look at and read should be encouraged. However, one mode of education is not enough given the very poor knowledge of parents as demonstrated by the results of this study. Leaflets should be supported by other methods including television and radio talk shows. Given the recent popularity of social media and the ease of access to smart devices here in Jordan (Pew research centre 2018), the option of delivering oral health education messages through social media should be investigated and compared to the more conventional use of leaflets.