Study of Parents’ KAP regarding their Children’s Oral Health and the Factors that Inuence Children’s Risk of Dental Caries

Background: Caries can harm children’s physical health, mental health, and overall development. To understand the factors that inuence children’s risk of dental caries and the status of dental caries among children in Beijing, China, aged 3–5 years and to determine parents' KAP regarding their children’s oral health. Methods: The research subjects were parents who accompanied their children to a hospital for dental examination, and parents who attended community-based oral-health consultations. Data were collected through a questionnaire survey. The data were statistically analyzed using SPSS software. Results: Overall, 41.4% of the children had dental caries. The parents had high demand for dental-caries-related knowledge, and were willing to receive such knowledge from a variety of sources. Logistic regression models showed that factors that impact children’s caries were the mother’s educational background, whether parents regularly acquire oral-health knowledge, and whether children have a dental examination each year. Conclusion: In Beijing, approximately half of the children aged 3–5 years have dental caries. Parents have good knowledge and attitudes regarding their children’s oral health, but their associated actions are insucient. Therefore, it is necessary to provide parents with assistance regarding managing children’s oral health.


Background
In global terms, oral health has always been considered an element of public health 1 . In 1998, Slade et al. began to study the oral-health-related quality of life (OHRQL) of adults and older people, 2 and scholars from various countries built on this by exploring OHRQL among children. 3 In 2003, Jokovic et al. designed a questionnaire concerning oral-health quality during early childhood, 4 and the following year Jokovic et al. studied OHRQL among 8-10-year-old children. 5 In recent years, the research focus has been further expanded. New topics include the relationship between poor oral health and the risk of falls among older adults, 6 between oral health and quality of life among patients with depression, 7 and between oral health and quality of life among malnourished patients. 8 Although there have been extensive studies of oral health, there remains a large gap in the research regarding oral-health-related knowledge, attitudes, and practices (KAP). Notably, the study of oral-health-related KAP can play a positive role in the prevention of oral diseases. 1 Furthermore, study of oral-health-related KAP among populations can help to maintain public-health levels.
In the eld of oral health, children's oral health is a major concern. In the eld of oral health, children's oral health is a major concern. However, to improve children's development, it is necessary to examine the current status of children's dental caries and parents' oral-health practices." Nevertheless, to improve children's development, experts should also examine the current status of children's dental caries and parents' oral-health practices.
Dental caries, as one of the major diseases that negatively in uence OHRQL, have a strong impact on people's lives, especially children who lack awareness of prevention techniques. 9,10 The in uencing factors of early childhood dental caries can be categorized into six risk factors: social demography, dietary habits, oral hygiene, oral ora, feeding methods, and other factors. 11 Overall, over 100 factors have been found to affect children's risk of dental caries but, despite this high number, most can be effectively prevented through scienti c measures. However, this requires parents to possess a certain level of knowledge regarding children's oral health, and to impart this knowledge upon their children. 12 Therefore, studying parents' KAP regarding their children's oral health and the factors that in uence children's risk of dental caries can have positive implications.
This study aims to conduct a basic survey, in Beijing, China, of parents' KAP concerning their children's oral health in an attempt to understand whether parents of children aged 3-5 years possess the basic KAP to ensure that their children have healthy oral health. The fundamental purpose of this study is to provide basic reference materials and explore the parent-related factors that affect children's dental caries, which can serve to raise parents' awareness of children's oral health and preventive measures for dental caries, and help reduce the incidence of dental caries in children.

Method
The research comprised three phases. The rst phase involved designing a questionnaire to obtain data.
The second phase consisted of data collection. And the last phase included a series of analysis for data.

Phase I: Questionnaire Design
Through an extensive literature review, 13,14 the present research group designed a questionnaire to test parents' oral-health knowledge. The questionnaire comprised six modules: the parents' and children's basic demographic information, parents' level of knowledge regarding oral health, parents' attitudes towards oral problems, parents' current practices for maintaining children's oral health, parents' level of demand for oral-health knowledge, and parents' preferred sources of oral-health knowledge. Parents' KAP regarding their children's oral health was measured through items scored using a ve-point Likert scale, ranging from "strongly agree" to "strongly disagree," or from "strong need" to "very little need." Phase II: Data Collection From August to December 2019, the data for this study were collected in Beijing. HaiDian Maternal & Child Health Hospital was the main location for data collection. In addition, community health service centers were an option for data collection. The inclusion criteria of participants were as follows: (1) parents who accompanied their children to hospital for a dental examination, or parents who attended community-based oral-health consultations regarding their children; (2) ability to exchange and contact with researchers and (3) willingness to receive this questionnaire survey. We excluded participants which their children have autism or other mental disease. After obtaining informed consent from respondents, professional personnel distributed and recovered the questionnaire.
Phase III: Data analysis All data were analyzed using the SPSS software package. Basic characteristic information was obtained by using descriptive statistics. The factors in uencing children's risk of dental caries were analyzed through multiple logistic regression analysis.

Basic characteristics
Overall, 2,200 questionnaires were distributed to the respondents, of which 2,078 were returned (response rate: 94.5%); however, 216 questionnaires did not relate to children aged 3-5 years. Hence, 1,862 responses were analyzed. The data concerned basic information regarding the respondents and their family members; primarily the children's ages, gender, and incidence of dental caries, the parents' respective education levels, how often the children underwent dental examinations, whether the children had undergone a dental examination within the past year, whether family members were involved in the oral-health industry, and whether parents had regular access to oral-health information (Table 1). Parents' KAP Parents' KAP regarding their children's oral health was described using means. The means for the parents' attitudes toward maintaining their children's oral health ranged from 4.63 to 4.70. More speci cally, the mean for the item "Teeth must be examined when the deciduous teeth germinate" was 3.28, that for " uoride toothpaste should be used after deciduous teeth germinate" was 3.63, that for "children's mouths should be cleaned after meals" was 3.95, and the means for the other knowledge questions averaged between 4.05 and 4.36. The means for controlling children's intake of sweets, sweetened beverages, and sweetened milk were 3.63, 3.88 and 3.76, respectively, and the remaining questions regarding practices averaged between 4.08 and 4.47 (Table 2). Most respondents chose "strong need" or "need" to describe their level of knowledge regarding dental caries ( Table 3). The data showed that respondents had a variety of preferences regarding sources of oral-health knowledge (Table 4). Factors in uencing children's risk of dental caries Overall, 58.4% of the respondents reported that their children had "no caries." The rest of the children were referred as "experiencing dental caries." This group comprised the following: "one cavity" (6.5%), "two cavities" (11.7%), "three cavities" (5.1%), "four cavities" (6.4%), and " ve or more cavities" (11.9%). Finally, the respective impacts of whether parents regularly acquired oral-health knowledge, whether children received one dental examination a year, and the parents' educational backgrounds were analyzed to determine whether these had any effect on children's risk of dental caries (Table 5). Abbreviations -β: regression co-e cient beta; SE: standard error.

Discussion
The results of this study highlight the relationship between dental caries in children aged 3-5 years and their parents' KAP regarding their children's oral health. The oral health of children aged 3-5 years is primarily the responsibility of their parents, which indicates that the main cause of dental caries in children is insu cient KAP among parents regarding their children's oral health. Parents' KAP is formed through the in uence of many factors. There is a correlation between the parents' education level and the time and energy they devote to acquiring oral-health knowledge. Additionally, the associated harms, the pathogenic factors, the treatment, and especially the prevention of dental caries are the oral-health topics for which parents lack su cient knowledge. In short, parents are mindful of their children's oral health, but show some de ciencies regarding their practices for protecting their children's oral health.
Parents' education levels in uence the number of dental caries their children have. Parents are an important resource of oral-health knowledge for children, and their associated KAP affects their children's formation of oral-health concepts. Previous studies have also focused on the relationship between parents' education levels and their children's oral health awareness, 15 and studies have shown that, by improving their knowledge and attitude towards oral health, parents can improve their children's oral health. 16 During the preschool period, parents are the primary persons responsible for their children's oral health, so parents should acquire su cient oral-health knowledge and implement relevant oral-healthpromotion activities to control their children's oral-health risks. 17 UK-based researchers have suggested that, to protect children's oral health, "health visitors" (i.e., publichealth nurses) should receive training in oral-health promotion, including how to perform oral-health risk assessments and guidance on evidence-based, up-to-date prevention measures. 18 On the other hand, in the US the "dental home" has been developed to foster a comprehensive, sustained, coordinated, familycentered approach to providing oral-health care among children. 19 The success of this initiative should be noted, and similar approaches should be considered in other countries. Such as, under the guidance of province-level, city-level and county-level centers for disease control and prevention in China, Chinese community health service centers or service stations have established corresponding dental homes or similar organizations. 20 In Beijing, parents' KAP regarding their children's oral health is improving, and they are paying more attention to their children's oral health. 21 The respondents of the present study showed high awareness of basic oral-health knowledge. There are several possible reasons for this. First, the economy, politics, and society in Beijing are relatively stable, and the development of public-health services related to oral health is relatively good. Second, public dissemination of health knowledge through social media can greatly enhance understanding of health knowledge among social groups. 22 Individuals who are seeking information about oral health can search the Internet for health information or consult an online health expert. Finally, parents' health awareness is increasing and they have more knowledge about the management of children's oral health. Therefore, among parents' KAP, knowledge and attitudes are improving. However, the current situation, in which children of parents with adequate oral-health knowledge continue to experience oral diseases, indicates that parents' oral-health-related actions, including supervision of children's brushing and educating children about proper brushing methods, require further analysis to better determine safeguarding measures for children's oral health.
To protect their children's oral health, parents must consider various factors, including food choices, dental cleaning, and dental replacement. Excessive consumption of sugar-rich foods in children increases the prevalence of dental caries. 23 Sweets, cakes, and sweet drinks contain large amounts of sugar, and parents should limit children's intake of such foods. However, parents continue to have di culty controlling the consumption of sugar-rich foods in children. First, sugar-rich foods are attractive to humans. 24 Second, parents can have busy work lives, meaning their ability to intervene in this regard is limited. Parents' level of oral-health knowledge is relatively good. However, their demand for knowledge concerning dental-caries-related diseases is relatively high, indicating that they lack knowledge in certain areas. First, general oral-health knowledge is relatively easy to obtain, but elements concerning the dangers associated with dental caries, the treatment of dental caries, and the prevention of dental caries remain relatively restricted to professional dental knowledge. For instance, the effects of various saliva components, including ph, buffering capacity, proteins, electrolytes, antioxidants, enzymes and minerals, on the generation of dental caries are largely known only to medical professionals. 25 Second, the high demand for knowledge indicates that regular oral examinations and contents and the correct methods of brushing teeth should be further publicized and explained by health-care organizations.
The respondents' preferred sources of oral-health knowledge revealed a high demand for prescribed health education, doctor-patient exchanges, classroom education, educational videos, mobile-or webbased resources, and examples using teeth models. In contrast, return telephone calls and visiting treatment sites showed low demand. Therefore, to promote oral-health knowledge, the above knowledge sources should be adopted, and practical actions for improving people's awareness of oral health knowledge should be applied. 26 Regular access to oral-health knowledge and accompanying children to examinations are factors that in uence dental caries in children. Active learning and understanding of oral-health-related knowledge among parents are conducive to timely health interventions for children and guidance that protects children's teeth. 27 Regular dental check-ups play a key role in maintaining oral health; 18 thus, parents should insist on regularly accompanying children to hospitals or community medical institutions for dental check-ups. More importantly, countries should explicitly include dental examinations in their health-care plans. 28 The results of this study only represent parents who have relatively high education levels and who are based in an economically developed city. It is important to note that there are several constraints regarding the ndings. First, the research focused on a speci c group, meaning the results are not completely generalizable. In future research, parents from less-developed areas or rural areas should be surveyed in order to compare the results. Second, there may be other problems (e.g., gum disease) that can better re ect the current situation of parents' KAP regarding children's oral health. These problems can be incorporated into future research, thereby constructing a more comprehensive understanding of parents' oral-health-related KAP. Finally, family economic status could be considered and compared with the frequency of dental exams, which could reveal additional factors that in uence dental caries in children.

Conclusions
In conclusion, the very common phenomenon of children have dental caries in Beijing, China. In the meantime, parents have insu cient actions regarding their children's oral health. This ndings contribute to the demonstration and have an important guiding role for the development of interventions to improve the parents' KAP regarding their children's oral health in China.

Why This Paper Is Important To Children's Parents
Children's parents should be aware of the various potential in uencing factors on early childhood dental caries.
Parents' KAP on Children's oral health is effective for protecting children's dental health.
List Of Abbreviations knowledge, attitudes, and practices KAP Declarations Ethics approval and consent to participate The research was con rmed to the ethical standards of Helsinki declaration. Each participant accepted to participate in the study were informed the topic and content about this survey.

Consent for publication
Not applicable.

Availability of data and material
The raw datasets of this study can be made available from the corresponding author on reasonable request.

Competing interests
The authors declare no con ict of interests.