This cross-sectional study focused on Chinese ethnicity, is the first study to observe family functioning as a mediating factor of disease-specific OHRQOL among pre-school children with childhood dental caries in Malaysia. Understanding of these impacts will aid the clinicians and researchers evaluate oral health needs, ascertain priorities of care and gauge the outcomes of treatments approaches.
Overall good family functioning and OHRQoL were observed among 4 to 6-year-old pre-school Chinese children in this study. The reason could be the socioeconomic factors of the sample, that only included pre-school children from an international school setting reflecting of high socioeconomic background. More than three-fourth of the parents had monthly income of above twelve hundred USD and almost all the children were living with both parents with small family structure. Chinese traditional culture is known for its strong and distinct family ethics, as part of this principled code of conduct in fostering children as their responsibilities, and in turn it ponders contentment and happiness.
The structure of the family is also associated with children’s dental health. In contrast to previous findings, this study found a significant association between family functioning and childhood dental caries. Almost all the children from poorer functioning families had dental decay than children from normal functioning families.9,31 Significant findings were noted with parents relationship to child with family functioning, it indicates the possibility that better family functioning is reported by fathers that is reflective of dominant role of males in Chinese culture. 32
The same children were also more likely to have poor OHRQoL. Quality of life is impacted by oral health under physical, social and psychological domains.33 In general similar association was seen with other studies that showed a relationship between family functioning and QOL,34–36 we found a statistically significant correlation between parental report of their family functioning and perception of their child's OHRQoL. The negative impact of dental caries on children’s OHRQoL is supported by previously reported findings. These impacts of oral pain, chewing and sleeping difficulties, changes in behaviours and decrease in school performance.37–39
Findings of this study confirms the association between the presence of dental caries and OHRQoL in young children in support to the previous studies.14,16,40 Several studies have verified the children’s parents responses for the OHRQoL,13–16 indicated that the dental caries’ impact on children’s life is frequently related to the symptoms, limitations and psychological aspects. The finding of this study support the previous findings with significance observed in all domains except in symptom domain.
The lack of association between symptom domain and caries status could be explained by the levels of caries severity observed during clinical examination. Almost all the children in this study had low severity that could reflect on child’s perception of pain in symptoms domain. Dental caries is marked as slow progressing disease with relatively stable clinical signs (white or light brown spots). During this stage the symptoms are not perceived by lay individuals as an indicator of disease activity or latency. The symptoms are more recognizable as the disease progresses (brown spots with slight or moderate pain).41
In relation to the previous study finding, sociodemographic characteristics does not show substantial association with OHRQoL.42 However in contrast to previous studies which reported families who have low socioeconomic status were more likely to rate their child‘s oral health ‘worse than other children,43 this could be due to high SES for majority of our sample. Supported by various researchers and policy makers, common risk factor approach proves to be the most effective strategy to be incorporated for the overall well-being of individuals.44,45 Feldens et al.45 established the relationship between healthy dietary habits and decreased caries incidence through a randomized control trial.
Locker proposed that the link between oral disease and health-related quality of life outcomes is interceded by personal and environmental factors.46 the findings of this study shows strong association between family functioning and caries status with OHRQoL. Ungar explained the construct of resilience among children who face adversity, good family functioning can be conceptualized as a relational protective process that predict positive outcomes.47 Family functioning medicate an environment for the development of dental caries which in turn would result in compromised OHRQoL.
The strengths of this study was evident by the use of reliable and valid instruments to assess OHRQoL and family functioning. The measures were reported to have good psychometric properties, and they gain attention from their source in theoretical models. However, some probable limitations should be taken into consideration, that includes our sample being from one ethnic group and belonging to affluent social class thus indicating for the limited generalizability. The cross-sectional nature of study design was one of the limitations associated with this research. Another concern could be of using self-report methods that rely on parents’ perceptions and beliefs and they could be diverse from the actual behaviours.48 Alternative possible limitation might be the 'Hawthorn effect' (parents’ reactivity to modify their behaviour in order to avoid embarrassment).49