Age and Reasons for First Dental Visit and Knowledge and Attitude of Parents Toward Dental Procedures for Puducherry Children Aged 0-9 years.

BACKGROUND: The first dental visit provides the dentist an opportunity to advise parents on prevention of oral diseases and also allows for early detection of caries and arrest of its progression. The first dental visit should occur no later than 12 months of age. However, parents fail to give importance to primary dentition as they feel that they are temporary. AIM: The aim of this study was to determine the age of first dental visit and most common reasons for the visit among children aged 0-9 years and to examine the knowledge and attitude of their parents toward treatment procedures for children, taking into account their socioeconomic and educational status.
MATERIALS AND METHODS: After obtaining informed consent from parents, sociodemographic data that included age and gender of the child, educational status, occupation of parents, and annual family income were collected. A validated questionnaire was given to the parents. STATISTICAL ANALYSIS USED: Descriptive statistics (proportion) was used to report the data. To examine differences in knowledge and attitudes among different socioeconomic and educational groups, chi-square test was used with P value <0.05.
RESULTS: A total of 300 completed questionnaires were analyzed. Age of first dental visit was 6-9 years (57%) and the most common reason for the visit was decayed teeth (33%). The overall attitude of parents toward treatment procedures for children was good in spite of low levels of knowledge about primary teeth and role of the pedodontist.
CONCLUSIONS: It is necessary to promote early dental visits by providing education on perinatal and infant oral healthcare to the healthcare professionals dealing with children. It is also important to promote awareness regarding the maintenance of primary dentition.

INTRODUCTION

The first dental visit is an important event in a child’s life. It provides the dentist an opportunity to advise parents on prevention of oral diseases and also allows for early detection of dental caries and arrest of its progression. It is recommended that the first dental visit should occur no later than 12 months of age.[1] In a study among children aged 5–17 years in Vidarbha region of Maharashtra, 85% children never visited a dentist till the age of 17 years.[2] Parents feel that primary teeth are temporary and hence fail to give importance to care and treatment of deciduous teeth. Other factors that influence early dental care are socioeconomic status, awareness and knowledge about infant oral health among pediatricians and general dentists, insurance coverage, and parent’s attitude toward early dental care.[3] The more positive a mother’s attitude regarding her child’s oral health, the more dental treatment the child will receive.[4]

This study was conducted to determine the age of first dental visit and most common reasons for the visit among children aged 0–9 years reporting to the Pediatric Dentistry department of a tertiary-care hospital at Puducherry and to examine the knowledge and attitude of their parents toward treatment procedures for children, taking into account their socioeconomic and educational status.

SUBJECTS AND METHODS

A cross-sectional study was conducted among parents of children aged 0–9 years reporting for their first dental visit to the Pediatric Dentistry department of a tertiary-care hospital at Puducherry. The period of data collection was from February to May 2017. The sample size was determined to be 300 using the software Open Source Epidemiologic Statistics for Public Health (version 3.01, updated April 6, 2013) using confidence limits as 5%, hypothesized percentage frequency of outcome factor as 70.3%[5], and confidence level as 99%. The study included 0- to 9-year-old children visiting the dentist for the first time and their parents who gave written informed consent to participate in the study. Children with special healthcare needs were excluded. The study was approved by the institutional ethical committee of the Indira Gandhi Institute of Dental Sciences (RID2017NRP09PGVVPPD). Sociodemographic details such as child’s age, gender, educational status, occupation of parents, and annual family income were collected. The questionnaire for this study was prepared using questionnaires of previous studies[56] and was tested for internal consistency and reliability (Cronbach α = 0.89). The questionnaire included questions on reasons for the visit, person who referred, reason for not taking the child earlier for dental consultations (eight options), eight questions on knowledge about primary teeth and Pediatric Dentistry speciality (options as yes/no), and nine questions on attitudes of parents toward various treatment procedures for children (options as yes/no). The parents were then educated on the importance of primary teeth and also about the various preventive, restorative, endodontic, and orthodontic treatment modalities for children.

STATISTICAL ANALYSIS

Epi Info software was used for statistical analysis. Descriptive statistics (proportion) was used to report the data. To analyze differences in knowledge and attitudes among different socioeconomic and educational groups, chi-square test was used with P value <0.05 considered as significant.

RESULTS

A total of 300 completed questionnaires were analyzed. Children were categorized into three groups based on age: 0–3 years, 3–6 years, and 6–9 years. Parents were categorized into seven educational groups and five socioeconomic groups [Figures 1 and 2]. A greater proportion of children brought for their first visit were in the age group of 6–9 years (57%). Only 3% were in the age group of 0–3 years [Figure 3]. All the parents were educated; 65% were graduates. Most of them were from upper-lower class (39%) and lower-middle class (36%) socioeconomic levels. The most common and least common reasons for first dental visit were decayed teeth (33%) and swelling (1%), respectively [Figure 4]. The most common reason for not having taken the child for early dental visits was that the child did not have any dental problem (55%) [Figure 5]. A high proportion of parents (75%) did not know that 6 months is the right time for first dental visit; 77% knew that milk teeth have to be preserved till they shed; and 58% of parents were aware about Pediatric Dentistry speciality. Nearly half of them knew that a pediatric dentist is trained in treating children with special needs. A poor knowledge was evident regarding the caries-protective role of fluoride: 51% of parents did not know that premature extractions of primary teeth can lead to malocclusion; 54% felt that milk teeth need treatment; and 18% thought that treating milk teeth will cause damage to permanent teeth. Majority of parents were willing for dental radiographs (96%), fluoride application (96%), sealant placement (97%), placement of space maintainers (94%), and early orthodontic treatment (95%). When given the choice of pulp therapy (capping/pulpectomy) or extraction for deep carious teeth, 83% of parents agreed with preserving the tooth with pulp therapy and 79% agreed for treatment under general anesthesia when the child had extensive dental problems and would not cooperate [Table 1]. The data were also analyzed to find if any significant differences in knowledge and attitude existed among different socioeconomic groups and parent educational levels. Statistically significant differences were found for the following questions: Knowledge about existence of separate speciality for children (greater among graduates and upper-middle class), treating milk teeth may cause damage to permanent teeth (28% of upper-lower class felt yes), early removal of milk teeth could lead to malocclusion (59% of graduates replied yes), treating primary teeth will cause damage to permanent teeth (90% of parents with primary school education felt “no,” 27% graduates felt “yes”, 28% parents of upper-lower class felt “yes,”). Among graduates, 74% preferred root canal treatment over extraction of primary teeth [Tables 2 and 3].

Figure 1

Educational status of parent

Figure 2

Socioeconomic status of the family

Figure 3

Age of first dental visit

Figure 4

Common reasons for first dental visit

Figure 5

Common reasons for not bringing the child for early dental visits

Table 1

Descriptive statistics for knowledge and attitudes of parents towards dental procedures for children

Knowledge
Q. No.	Questions	Yes n(%)	No n(%)
1	Do you know that we have 2 sets of teeth- Milk teeth and permanent teeth?	263 (87.7)	37 (12.3)
2	First dental visit of the child should be at 6 months of age?	75 (25)	225 (75)
3	Do you think milk teeth are important and have to be preserved till they fall on their own?	231 (77)	69 (23)
4	Do you know that there is a separate specialty called pediatric dentistry?	175 (58.3)	125 (41.7)
5	Do you know that fluoride can prevent tooth decay?	77 (25.7)	223(74.3)
6	Do you know that early removal of teeth will cause malocclusion?	147 (49)	153 (51)
7	If your child suffered trauma to teeth and gums, Do you know that you have to take your child immediately to the dental clinic?	265 (88.3)	35 (11.70)
8	Do you know that a pediatric dentist is trained in providing dental care for children who have disabilities and medical problems?	161 (53.7)	139 (46.3)
Attitude
1	Do you think milk teeth need dental treatment?	162 (54)	138 (46)
2	Do you think treating milk teeth will cause damage to permanent teeth?	53 (17.7)	247 (82.3)
3	If your dentist advices X - rays for your child’s teeth will you agree for it	289 (96.3)	11 (3.7)
4	In order to prevent tooth decay the dentist advices cleaning of teeth and fluoride application on your child’s teeth. Will you agree for it?	287 (95.7)	13 (4.3)
5	In order to prevent tooth decay in your child’s teeth, your dentist advices to get a white coating placed on the grooves in the teeth, will you agree?	290 (96.7)	10 (3.3)
6	If your child has a badly decayed tooth and the dentist advises preserving it with filling/ root canal treatment, will you prefer root canal treatment over extraction?	250 (83.3)	50 (16.7)
7	Your child’s milk teeth have to be removed before the natural time of their shedding and your dentist advices placement of a clip to preserve the space. Will you agree	281(93.7)	19 (6.3)
8	If your dentist finds a major problem in the alignment in child’s teeth/ jaw and advices to start clip treatment during growing period. Will you accept it	285 (95)	15 (5)
9	If your child is not co-operating for dental procedures and has extensive dental problem and your dentist advices treatment to be done under general anesthesia or conscious sedation, will you agree for it?	237 (79)	63 (21)

Table 2

Association between knowledge and attitude and Socioeconomic status of parents

Q. No.	Socio-Economic Status								P value
	Upper		Upper-Middle		Lower-Middle		Upper-Lower
	Yes n (%)	No n (%)	Yes n (%)	No n (%)	Yes n (%)	No n (%)	Yes n (%)	No n (%)
Knowledge
1	2 (100)	0	70 (97.2)	2 (2.8)	98 (90.7)	10 (9.3)	93 (78.8)	25 (21.2)	0.001*
2	1 (50)	1 (50)	20 (27.8)	52 (72.2)	19 (17.6)	89 (82.4)	35 (29.7)	83 (70.3)	0.139
3	2 (100)	0	58 (80.6)	14 (19.4)	87 (80.6)	21 (19.4)	84 (71.2)	34 (28.8)	0.247
4	2 (100)	0	48 (66.7)	24 (33.3)	48 (44.4)	60 (55.6)	77 (65.3)	41 (34.7)	0.002*
5	1 (50)	1 (50)	27 (37.5)	45 (62.5)	21 (19.4)	87 (80.6)	28 (23.7)	90 (76.3)	0.040*
6	1 (50)	1 (50)	39 (54.2)	33 (45.8)	47 (43.5)	61 (56.5)	60 (50.8)	58 (49.2)	0.526
7	2 (100)	0	65 (90.3)	7 (9.7)	97 (89.8)	11 (10.2)	101 (85.6)	17 (14.4)	0.655
8	1 (50)	1 (50)	49 (68.1)	23 (31.9)	42 (38.9)	66 (61.1)	69 (58.5)	49 (41.5)	0.001*
Attitude
1	2 (100)	0	48 (66.7)	24 (33.3)	52 (48.1)	56 (51.9)	60 (50.8)	58 (49.2)	0.040*
2	0	2 (100)	12 (16.7)	60 (83.3)	8 (7.4)	100 (92.6)	33 (28)	85 (72)	0.001*
3	2 (100)	0	71 (98.6)	1 (1.4)	104 (96.3)	4 (3.7)	112 (94.9)	6 (5.1)	0.614
4	2 (100)	0	71 (98)	1 (1.4)	0	6 (5.6)	112 (94)	6 (5.1)	0.53
5	2 (100)	0	71 (98.6)	1 (1.4)	104 (96.3)	4 (3.7)	113 (95.8)	5 (4.2)	0.739
6	2 (100)	0	60 (83.3)	12 (16.7)	95 (88)	13 (12)	93 (78.8)	25 (21.2)	0.284
7	2 (100)	0	69 (95.8)	3 (4.2)	100 (92.6)	8 (7.4)	110 (93.2)	8 (6.8)	0.812
8	2 (100)	0	67 (93.1)	5 (6.9)	104 (96.3)	4 (3.7)	112 (94.9)	6 (5.1)	0.786
9	2 (100)	0	55 (76.4)	17 (23.6)	86 (79.6)	22 (20.4)	94 (79.7)	24 (20.3)	0.829

Table 3

Association between knowledge and attitude and educational levels of parents

Q. No.	Educational status										P value
	Graduate		Diploma		High school		Middle school		Primary school
	Yes n (%)	No n (%)	Yes n (%)	No n (%)	Yes n (%)	No n (%)	Yes n (%)	No n (%)	Yes n (%)	No n (%)
Knowledge
1	85 (91.4)	8 (8.6)	86 (84.3)	16 (15.7)	52 (85.2)	9 (14.8)	3 (75)	1 (25)	36 (92.3)	3 (7.7)	0.535
2	31 (33.3)	62 (66.7)	25 (24.5)	77 (75.5)	10 (16.4)	51 (83.6)	0	4 (100)	9 (23.1)	30 (76.9)	0.179
3	68 (73.1)	25 (26.9)	78 (76.5)	24 (23.5)	45 (73.8)	16 (26.2)	4 (100)	0	35 (89.7)	4 (10.3)	0.284
4	68 (73.1)	25 (26.9)	53 (52)	49 (48)	29 (47.5)	32 (52.5)	3 (75)	1 (25)	21 (53.8)	18 (46.2)	0.013*
5	29 (31.2)	64 (68.8)	21 (20.6)	81 (79.4)	12 (19.7)	49 (80.3)	3 (75)	1 (25)	12 (30.8)	27 (69.2)	0.075
6	55 (59.1)	38 (40.9)	36 (35.3)	66 (64.7)	31 (50.8)	30 (49.2)	1 (25)	3 (75)	23 (59)	16 (41)	0.010*
7	85 (91.4)	8 (8.6)	88 (86.3)	14 (13.7)	51 (83.6)	10 (16.4)	4 (100)	0	36 (92.3)	3 (7.7)	0.572
8	65 (69.9)	28 (30.1)	49 (48)	53 (52)	24 (39.3)	37 (60.7)	2 (50)	2 (50)	20 (51.3)	19 (48.7)	0.004*
Attitude
1	50 (53.8)	43 (46.2)	48 (47.1)	54 (52.9)	35 (57)	26 (42)	2 (50)	2 (50)	26 (67)	13 (33)	0.341
2	25 (26.9)	68 (73.1)	16 (15.7)	86 (84.3)	7 (11.5)	54 (88)	0	4 (10)	4 (10.3)	35 (89)	0.014*
3	92 (98.9)	1 (1.1)	98 (96.1)	4 (3.9)	56 (91.8)	5 (8.2)	4 (100)	0	38 (97.4)	1 (2.6)	0.341
4	89 (95.7)	4 (4.3)	94 (92.2)	8 (7.8)	60 (98.4)	1 (1.6)	4 (100)	0	39 (100)	0	0.297
5	89 (95.7)	4 (4.3)	98 (96.1)	4 (3.9)	59 (96.7)	2 (3.3)	4 (100)	0	39 (100)	0	0.863
6	16 (74.2)	24 (25.8)	85 (83.3)	17 (16.7)	58 (95.1)	3 (4.9)	3 (75)	1 (25)	34 (87.2)	5 (12.8)	0.029*
7	89 (95.7)	4 (4.3)	95 (93.1)	7 (6.9)	56 (91.8)	5 (8.2)	4 (100)	0	36 (92.3)	3 (7.7)	0.912
8	90 (96.8)	3 (3.2)	93 (91.2)	9 (8.8)	60 (98.4)	1 (1.6)	4 (100)	0	37 (94.9)	2 (5.1)	0.361
9	73 (78.5)	20 (21.5)	75 (73.5)	27 (26.5)	53 (86.9)	8 (3.1)	3 (75)	1 (25)	32 (82.1)	7 (17.9)	0.458

DISCUSSION

Age at first dental visit

The first dental visit should begin during pregnancy to advise the expectant mother on the importance of dental visit at 6 months of age.[7] The average ages of first dental visit described in various studies are as follows: >6 years,[3] 5–12 years,[2] 5 years,[8] 3–5 years,[9] and 14.92 months.[10] This study revealed that most of the children are brought for their first dental visit between 6 and 9 years. Universally, awareness about the age of first dental visit is low. In Chennai, 59% of parents of children aged 3 months to 10 years reported that the first visit should be only after permanent teeth erupt.[11] In a study among parents of children aged 1–5 years in Waghodia Taluka, Gujarat, 35% supported that the first dental visit should be by 1 year of age.[12] In a survey among 1300 parents in Mumbai city, 39% believed that the first dental visit should be at 1 year of age.[6] In a study among parents of Malaysian children attending a university pediatric dental clinic, 84% disagreed that the first dental visit should be before the child’s first birthday because teeth are not complete (36%), no disease at this age (24%), and child will be uncooperative (24%).[13]

Reasons for first dental visit

Most common reasons for the first dental visit in the various studies conducted were pain followed by dental caries,[14] pain followed by regular checkups[2], and pain and other dental emergencies (trauma and infection).[9] The results of this study were similar to the previous studies, in that the most common reason was decayed teeth followed by pain. Irrespective of socioeconomic status, majority of parents in a study conducted in Nasik felt that the child should be taken to first visit after complains of tooth pain.[15] In contrast to the previous studies, majority of Malaysian parents felt that the main reason to see dentist for the first time should be for a checkup.[13] Similarly, a study among 844 children aged 0–36 months at the University of Sao Paulo showed orientation/prevention as the predominant reason for seeking dental care; the second common reason was caries/treatment followed by dental trauma.[10]

Reasons for not visiting the dentist earlier

A study conducted in an Indian population found the following potential barriers for parental failure to bring children to dental clinic: lack of knowledge regarding importance of oral health, treatment cost and time, missing school, daily work load, fear of treatment, and multiple visits.[16] This study enquired the reasons why children were not taken to dentist earlier for which majority reported that their child did not suffer from any dental problem. This could be due to low level of awareness on the process of dental caries and preventive services available to control dental caries. Also, parents feel that the child will not be able to cooperate as he/she is young. This is because of the low awareness regarding the availability of pediatric dentists; 42% of parents in this study were not aware about a separate speciality for children’s dental care. The results are similar to the survey among parents in Mumbai in which 49.6% parents were aware that a pediatric dentist is a specialist trained in child psychology and management.[6] In this study, 40% of the parents were referred from dental camps and medical hospitals, whereas the remaining 60% came on their own will. A study reported that most parents would take the child first to a pediatrician and very rarely to a pedodontist when the child complains of pain. They expect that the pediatricians would refer them to an appropriate dentist.[12] In another study, 76% of parents would visit a physician for oral healthcare needs and only 4.7% would visit a pedodontist. The rest would visit either a general dentist (10.4%) or a pediatrician (8.5%).[17]

Knowledge and attitudes toward treatment procedures for children

Fifty-one percent of parents did not know that premature extractions of primary teeth can lead to malocclusion. The results are similar to the findings among parents of Malaysian children, 49% of whom indicated that early loss of primary teeth may affect eruption of permanent teeth.[13] Many parents have no knowledge about the variety of treatment options available for primary teeth and they think that such broad range of treatments are available only for permanent teeth of adults.[14] In this study, 54% of parents felt that milk teeth need treatment. However, it is very reassuring to note that only 18% felt that treating milk teeth will cause damage to permanent teeth. In a study among parents of Kannur suburban, 75% felt that pulp therapy will cause problem in permanent dentition.[18] In a study among parents of Malaysian children, 37.5% felt extraction to be the best treatment choice for primary teeth with caries.[13] In a survey among 1300 parents in Mumbai city, 49.8% were aware about the protective role of fluoride and 55.5% were willing for fluoride application and sealant treatment.[6] In KwaZulu-Natal, South Africa, 32% of parents were hesitant or unwilling to have sealants placed.[19]

There is also a common belief that cleaning of teeth would loosen them and scratches would appear on teeth. There is also fear of use of sedation and general anesthesia for children as parents feel that the medicines would affect the development of child’s brain, affect their memory, and exacerbate symptoms of existing disease. It is also important to consider the social support from other members of the family when giving consent for treatment procedures to be carried out on primary teeth in children. Many dental professionals inform parents that the child is too young to cooperate and the child needs to wait till he is old enough. All these affect the parents’ beliefs regarding dental treatment for children.[20] Tickle et al., in their study conducted among UK parents, found that majority of parents preferred to leave treatment decisions to the dentist, reflecting the imbalance in knowledge existing between parents and healthcare professionals. Parents may not have understanding about health problems and treatment modalities available and their effectiveness. Therefore, it is the responsibility of the dentist to educate the parents about importance of primary teeth and their treatment so as to enable them provide informed consent for the dental care of their children. In the same study, parents whose children had fillings or extractions in the past were more likely to prefer the same treatments if their child had toothache.[21] This factor of experiential knowledge gained from dental visits of other children in the family could have influenced the attitude component of this study. Surprisingly, in this study majority of parents were willing for most of the dental procedures, reflecting a general good attitude toward treatment procedures for children.

Knowledge and attitudes of parents among various socioeconomic and educational groups

In this study, the overall educational status of parents is good with 85% of them having done high school education and above. Irrespective of the educational status, majority of parents were not aware of the time of first dental visit. Interestingly, most parents knew that milk teeth have to be preserved till they shed and amongst all the educational levels, the primary school education group showed higher knowledge (89.7%).

The proportion of parents who felt that treating milk teeth will cause damage to permanent teeth was more among the higher educational levels and upper-lower socioeconomic status, and this difference was statistically significant. Increased access to inaccurate and misleading information from various Internet sources could be a reason for this observation among the highly educated parents. The awareness about the protective role of fluoride against dental caries is low across the various socioeconomic groups; however, more parents from upper-middle class group were aware about it. A similar pattern was seen for the awareness about the fact that pediatric dentists are trained in treating children with special needs.

LIMITATIONS

The study was conducted among a small sample of rural population of Puducherry.

FUTURE PERSPECTIVES

Future studies should be conducted among samples representing both rural and urban population of Puducherry. The influence of knowledge and attitude of grandparents on the oral health of children should also be studied. It would also be relevant to know the barriers affecting early dental care. It is also essential to educate the population on the importance of early dental care and study the effects of such intervention on the knowledge and attitude of parents.

CONCLUSION

There is an urgent need to promote early dental visits and create awareness about the importance of primary dentition. This could be achieved by providing education on perinatal and infant oral healthcare to medical students, obstetricians and gynecologists, pediatricians, family physicians, and nursing personnel whose messages about healthcare are much valued by parents. Pediatric dentists should work in close collaboration with these professionals to prevent children from falling prey to the serious complications of early childhood caries as “every child has a fundamental right to total oral health and every Pedodontist in particular has an obligation to uphold this right.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.