Influence of Parents’ Oral Health

International Journal of Paediatric Dentistry

2002;

12:

101108

2002 BSPD and IAPD

101

Blackwell Science Ltd

Influence of parents oral health behaviour on oral health status of their school children: an exploratory study employing a causal modelling technique

M. OKADA

1

, M. KAWAMURA

2

, Y. KAIHARA

1

, Y. MATSUZAKI

1

,

S. KUWAHARA

1

, H. ISHIDORI

1

& K. MIURA

1

1

Department of Paediatric Dentistry and

2

Department of Preventive Dentistry, Hiroshima University Faculty of Dentistry, Minami-ku, Hiroshima, Japan

Summary.

Objectives.

The aim of this study was to examine the simultaneous inter-relationships between parents oral health behaviour and the oral health status of theirschool children.

Sample and methods.

Subjects comprized 296 pairs of parents (mother or father) andtheir children at an elementary school in Hiroshima. The childs dental examinationwas performed using the World Health Organization (WHO) caries diagnostic criteriafor decayed teeth (DT) and filled teeth (FT). The Oral Rating Index for Children (ORI-C) was used for the childs gingival health examination. Hiroshima University DentalBehavioural Inventory (HU-DBI) was used for the assessment of the parents oral healthbehaviour. A parentchild behavioural model was tested by the linear structural relations(LISREL) programme.

Results.

There was a significant correlation between DT and ORI-C (

r

= 0168;

P

< 001).Correlation was found between ORI-C and oral health behaviour in children (OHB-C)(

r

= 0182;

P

< 001). OHB-C was significantly associated with the HU-DBI (

r

= 0251;

P

< 0001). The hypothesized model after some revisions was found to be consistentwith the data (

2

= 13, d.f. = 6,

P

= 097; Goodness of Fit Index = 0999). Parentsoral health behaviour affected their childrens oral health behaviour (

P

< 0001). Chil-drens oral health behaviour affected their DT through its effect on gingival health level.Parents oral health behaviour also had a significant direct effect on their childrensDT (

P

< 005). Childrens grade affected both DT and their oral health behaviour.

Conclusions.

Parents oral health behaviour could influence their childrens gingivalhealth and dental caries directly and/or indirectly through its effect on childrens oralhealth behaviour.

Introduction

Adoption of consistent behavioural habits in childhoodtakes place at home, with the parents, especially the

mother, being the primary model for behaviour [1].To prevent dental caries and gingivitis, a motherssupport is essential. Sasahara

et al

. [2] showed thatmothers gingival condition, as a result of oralhealth behaviour, was associated with the prevalenceand severity of dental caries in their 3-year-oldchildren. Sarnat

et al

. [3] also reported that, at theages of 5 to 6 years, the more positive the mothersattitude regarding her child, the fewer caries the

Correspondence: Dr Mitsugi Okada, Department of PaediatricDentistry, Hiroshima University Faculty of Dentistry, 12-3Kasumi, Minami-ku, Hiroshima 7348553, Japan. E-mail:[email protected]

IPD_338.fm Page 101 Tuesday, March 12, 2002 6:23 PM

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child had, the better the childs oral hygiene, andthe more dental treatment the child received. Thereare few studies of parents influence on gingivalhealth of their school children by stage of childhooddevelopment. It has been reported that, althoughschool children believed that appropriate behaviourscould promote health, they did not develop anawareness of this relationship until the third andfourth grade [4]. From the point of view of Bandurassocial cognitive theory [5], overt behaviours ofsignificant others represent important sources ofsocial influence.

Socialization to oral health behaviours may beconsidered a modelling process in which childrenimitate the behaviour of their parents, who are avail-able and who provide valued role models for theiroffspring [5]. Parental modelling has proved to bea powerful means of establishing novel behavioursamong children, such as tooth brushing behaviour[6], but has rarely been studied as a behaviouralfactor with simultaneous interrelationships amongvariables of oral diseases.

Linear structural relations (LISREL) analysisprovides an opportunity to evaluate an entire set ofrelationships at the same time [7]. It has severaladvantages over traditional statistical methods, par-ticularly as it explores the causal links rather thanmere empirical relationships between variables. Inaddition, knowledge of the methodological adequacyof the data-gathering process and the quality of meas-urement instruments can be directly incorporatedinto LISREL models by estimating the proportion ofthe variance in an indicator that is error variance.The aim of the present study was to examine thesimultaneous interrelationships between parentsoral health behaviour and oral health status of theirschool children by using the LISREL.

Theoretical model

The construction of a hypothesized model (Fig. 1)is based on the findings of earlier studies [16,813]of factors affecting oral health. It was hypothesizedthat parents oral health behaviour is linked to oralhealth status (dental caries and gingivitis) of theirschool children directly, or indirectly through chil-drens oral health behaviour. It was hypothesizedthat dental caries of school children are causallylinked to their gingival health level, which reflectsoral hygiene status (self-care level). Children withpoorly controlled oral hygiene would suffer signi-

ficantly more from tooth decay than those with goodcontrol. It was hypothesized that childrens gradeand decayed teeth had direct effects on the numberof filled teeth.

Sample and methods

The study was conducted at an elementary schoolin 1998 among a sample of 712-year-old childrenin Hiroshima, Japan. Consent for this survey wasreceived from their parents prior to the study throughtheir schoolteachers. The parent (either mother orfather) was asked to answer a questionnaire aboutthe oral health behaviour of his/her child (OHB-C).Five items in the OHB-C concerned daily brushing,brushing frequency, use of floss, regular dental visitand regular snack-time (Table 1). For each item, theappropriate response was determined throughconsideration of current information about the topicaddressed by the item. A higher score indicatesbetter dental health behaviour of children. TheHiroshima University Dental Behavioural Inventory(HU-DBI) [14] was used for the assessment ofparents oral health behaviour. The maximum scoreof the HU-DBI was 12. A higher score indicatesbetter oral health behaviour. It has been shown tobe internally consistent (Cronbachs alpha = 076)[15]. The HU-DBI had a good testretest reliability(073) over a 4-week period [16]. Three hundred andeight parents (mother or father) responded to this sur-vey. The participation rate was 76%. Ten parents didnot complete the HU-DBI questions. The mother tofather ratio in the participants was 13 : 2. The meanage of the parents was 377 years (standard deviation:44 years).

Fig. 1. Construction of a hypothesized model. Influence ofparents oral health behaviour on both oral health behaviour andoral health status of their school children.


Parents influence childrens oral health

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Oral examinations took place at school for allchildren, with the exception of two who were absentfrom school. The ORI-C, which consists of five cat-egories (+2, +1, 0, 1, 2), was used for gingivalhealth examination as previously described [17]. Itwas performed by a paediatric dentist (MO), usingnatural light with children seated in a chair, with aset of standard photographs of each level of thescale to maintain consistent standards. Next, thechildren were dentally examined by three specialistpaediatric dentists (YK, SK, HI) using the WorldHealth Organization (WHO) caries diagnostic cri-teria for DMFT (decayed teeth, missing teeth, filledteeth) [18]. The examination took place with thesubjects in a supine position, using an artificial light,a dental explorer and a dental mirror. The mean per-centage agreement among the dentists was morethan 90% (YK versus SK 92%, SK versus HI 95%,HI versus YK 91%) for the inter-examiner reproduc-ibility for DMFT criteria in a sample of 20 ele-mentary school children. Subjects included 296 pairsout of 406 parents and their children (213 boys and193 girls). Thirty-nine fathers and one person whodid not report his/her sex distinction were includedamong 296 respondents.

Descriptive statistics (means and standard devi-ations) and correlation coefficients were used to pro-vide preliminary information about the associationsbetween six selected parameters. All paths connectingthe error components were set to unity. The overallfit was assessed by four measures: the chi-squaretest, the goodness of fit index (GFI), the adjustedgoodness of fit index (AGFI) and the root meansquare error of approximation (RMSEA). In thisstudy, the quality of model fit was considered reason-able, with the probability of a greater chi-squarevalue than the obtained values not less than 005,GFI (AGFI) greater than 090 and, after standard-ization, RMSEA less than 005. Statistical analyses

were conducted using SPSS 100 J and Amos 40(SPSS Inc., Chicago, Illinois, USA; SmallWatersCo., Chicago, Illinois, USA).

Results

Table 1 presents the percentage distribution of theparents with agree responses for each item on theOHB-C, for the total sample, and boys and girlsseparately. More than 80% of the parents reportedthat their child brushed his/her teeth everyday.However, 84% stated that their child had never useddental floss. Only 29% reported that their child wentto see the dentist periodically. Table 2 showsdescriptive statistics of and correlation coefficientsamong six selected variables. The mean scores ofDT, FT, OHB-C and HU-DBI were 037, 193, 250and 500, respectively. Cronbachs alpha was 051for the OHB-C. There was a significant correlationbetween DT and ORI-C (

r

= 0168;

P

< 001).Correlation was found between ORI-C and OHB-C(

r

= 0182;

P

< 001). OHB-C was significantlyassociated with HU-DBI (

r

= 0251;

P

< 0001).When the initial model was estimated, the chi-square was 139 ( d.f. = 6,

P

= 003), suggesting thatthe model did not fit the data. LISREL diagnosticinformation led us to allow the childs grade toaffect his/her oral health behaviour. Although nodirect path was initially hypothesized from childsgrade to DT, LISRELs modification index alsosuggested this, so that the path linking grade to DTwas added. With these changes, the overall revisedmodel was judged to be satisfactory (

2

= 13;d.f. = 6,

P

= 097, GFI = 0999, AGFI = 0995,RMSEA = 0000). The outline of our final model isgiven in Fig. 2. Parents oral health behaviour hada negative direct path to DT (014,

P

< 005) andalso had an indirect effect on childs gingival healththrough childs oral health behaviour. It was found

Table 1. Percentage distribution of the parents with agree responses for each item on childrens oral health behaviour (OHB-C).

No. Item descriptionsBoys

(n = 148)Girls

(n = 148)Chi-square

testTotal

(n = 296)1. My child brushes his/her teeth every day(A) 81 88 NS 842. My child brushes his/her teeth more than twice a day(A) 71 83 * 773. My child never uses dental floss(D) 84 84 NS 844. My child goes to see the dentist periodically(A) 26 32 NS 295. My child has a snack at a certain time every day(A) 49 43 NS 46

In the calculation of the OFIB-C: (A)One point is given for each of these agree responses. (D)One point is given for each of thesedisagree responses. Cronbachs alpha = 051. Significant differences between boys and girls; *P < 005, NS = not significant.


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that childs gingival health had a negative effect onDT (015,

P

< 001) and that DT had a negativeeffect on FT (019,

P

< 0001). Childs grade hada positive effect on FT (049,

P

< 0001). Childsoral health behaviour did not have any significanteffect on DT. In addition, the direct effect ofparents oral health behaviour on childs gingivalhealth was not significant. Further, the sign of thecoefficient for the association between childs gradeand oral health behaviour was negative (016,

P

< 001). There were some striking differences forthe values of model parameters for the genders(Figs 3 and 4), although the same model fitted thedata well for boys and for girls. For boys, parentsoral health behaviour had a significant effect on DT(017,

P

< 005), whereas for girls it was not signi-ficant. Conversely, for boys their gingival health didnot have any significant effect on DT, whereas forgirls it was significant (018,

P

< 005).

Discussion

The results of this study showed that parents oralhealth behaviour had a direct influence on theirchildrens number of decayed teeth. Furthermore,parents oral health behaviour had an indirect effecton gingival health level of their children throughchildrens own oral health behaviour. The finding isin agreement with those of Sasahara

et al

. [2], Sarnat

et al

. [3] and strom & Jakobsen [9], who reporteda significant correlation between parental oral healthbehaviour and their childs oral health behaviour.

The findings of this study support the importanceof the continued emphasis on parents self-carestrategies for not only their oral health but also theirchildrens oral health. Sallis & Nader [8] presenteda conceptual model of family influences on healthbehaviour. The model comprizes four major compon-ents: (i) the family environment and interrelationships

Table 2. Descriptive statistics of and correlations among six selected variables.

Grade DT FT ORI-C OHB-C HU-DBI

n 296 296 296 296 296 296Mean 351 037 193 008 250 500SD 172 102 192 092 125 216Grade 1DT 0139* 1FT 0466*** 0119* 1ORI-C 0052 0168** 0005 1OHB-C 0158** 0073 0103 0182** 1HU-DBI 0011 0153** 0002 0079 0251*** 1

Grade = childs school grade; DT = the number of decayed teeth; FT = the number of filled teeth; ORI-C = oral rating index for children;OHB-C = childs oral health behaviour; HU-DBI = parents oral health behaviour. Pearsons correlation coefficient (*P < 005, **P < 001,***P < 0001).

Fig. 2. Outline of the final model. Childsgrade = childs school grade; decayedteeth = childs number of decayed teeth;filled teeth = childs number of filled teeth;gingival health = score assessed by theORI-C; childs oral health behaviour =OHB-C score; parents oral health beha-viour = HU-DBI score. The overall fit wasassessed by four measures: chi-square test,GFI (goodness of fit index), AGFI (adjustedgoodness of fit index) and RMSEA (rootmean square error of approximation). Thestandardized regression weights are displayednear single-headed arrows in the path diagram.*P < 005, **P < 001, ***P < 0001.



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between health behaviours of the family mem-bers; (ii) the antecedents and consequences ofhealth behaviours; (iii) the influential mechanisms,namely response facilitation, observational learningand observation of consequences; and (iv) externalinfluences.

strom & Jakobsen [9] also reported that therewere statistically significant associations of use ofdental floss, tooth brushing and drinking of non-sugared mineral water among parents and theiradolescent offspring. Stewart

et al

. [10] showed thatthere was a statistically significant increase in self-efficacy for brushing and flossing following psy-chological interventions to improve oral hygienebehaviour. In Japan, most people do not know howto use dental floss [19,20]. Although the role ofsocial cognitive variables on oral hygiene behaviour(the daily removal of dental plaque by brushing andflossing) has received little research attention in Japan,children who have been encouraged in their preven-tive health behaviour may have self-efficacy duringgrowth and development. In this study, parents oralhealth behaviour had a direct effect on DT for boys,whereas for girls it had an indirect effect on DTthrough their oral health behaviour and gingival

health. There may be different mechanisms for causalmodels in boys and girls. School children as a wholewho consciously try to maintain good oral health,then, do in fact practice good health behaviours.

Some modifications to our initial model were sug-gested from the Amos programme [21]. For exam-ple, the path from childrens grade to their oralhealth behaviour was added as it was theoreticallyplausible to consider that childrens educationallevel might explain and influence their brushingbehaviour. In the current study, childrens grade wasnegatively linked to their oral health behaviour, theopposite to what was expected. This path was nec-essary to provide a good fit to the data. One possiblereason for finding a negative path from grade to oralhealth behaviour might be that some children havenot brushed and flossed their teeth willingly. Formost Japanese mothers, the extent to which theycheck up on their childrens teeth and oral hygienegradually decreases until the child starts elementaryschool [22]. Another reason might be that dentistsgenerally treat their patients when they have dentalpain and have not encouraged their patients brush-ing and flossing, although behavioural managementis considered as the treatment of choice [23].

Fig. 3. Outline of the final model (boys). Illustrationlegends are the same as those in Fig. 2.

Fig. 4. Outline of the final model (girls). Illustrationlegends are the same as those in Fig. 2.


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There are limitations in the methods and results ofthis study. First, parents educational level and socialclass were not accounted for in the model. Eccleston[24] wrote, however, In Japan there are less signi-ficant social or class divisions. There is believed tobe less socio-economic variation in Japanese culturethan in other countries. Approximately 95% of peoplego to senior high school and most people would bedescribed as coming from middle class backgrounds.All people in Japan are covered under medical anddental insurance. Questions such as personal financeor educational level are considered sensitive issuesto Japanese people; including such questions wouldbe likely to reduce the participation rate dramatic-ally. Also, items with regard to fluoride were notincluded. One of the reasons was that the items onfluoride seemed to have a problem of face validityin Japan: fluoride application has so far reached onlya small percentage of the Japanese population [25]and people appeared less well-informed on the bene-fits of water fluoridation [26].

Secondly, the participation rate of the presentstudy was not high. Parents having negative attitudestoward oral health care would be unlikely to haveresponded to the questionnaire. Therefore, the realstate of parentchild relations may differ to someextent from that shown in the model. Thirdly, theinternal reliability of the OHB-C was not adequateto assess childrens oral health behaviour. Furtherresearch is needed to examine and develop its metricproperties of reliability and validity. Fourthly, it mightbe better to investigate the influences of fathers andmothers oral health behaviour separately. When thedata for 256 mothers were analysed, the causal rela-tionship was almost the same as that in Fig. 2(results not shown). This study, however, was notintended to clarify differences in parental back-ground. It is common in Japan for mothers withschool-age children not to work outside the home.Ozawa [27] reported that Japans labour market isstill shaped by the uniform assumption that men gooutside to work while women maintain the home.The mother to father ratio in the participants mayreflect these circumstances. Fifthly, in cross-sectionalstudies, the causal interpretation of LISREL (likeany other multivariate statistical method) is funda-mentally incorrect. Prospective, longitudinal researchemploying causal modelling techniques might beneeded to clarify the nature of these relationships.

Despite the above-mentioned shortcomings of thisstudy, it can be seen that gingival health status of

school children and their parents oral health beha-viour have significant direct relationships with thechildrens dental caries. Parents oral health beha-viour could influence their childrens gingival healthand dental caries directly, or indirectly through itseffect on childrens oral health behaviour, althoughdifferences in cultural background and educationbetween countries may have contributed to the trendseen in the results of this study.

Rsum.

Objectifs.

Cette tude a eu pour objectifdexaminer les interrelations simultans entrelhygine buccale des parents et ltat de santbuccale de leur enfant scolaris.

Mthodes.

Sujets comprenant 296 paires parents(pre ou mre) et leurs enfants dans une colelmentaire de Hiroshima. Lexamen dentaire delenfant a t ralis laide des critres diagnos-tiques de carie de lOrganisation Mondiale de laSant (OMS) pour les dents caries (DT) et obtures(FT). Lindice dvaluation buccal pour les enfants(ORI-C) a t utilis pour lexamen de la santgingivale des enfants. Le HU-DBI (Evaluation decomportement dentaire de lUniversit de Hiroshima)a t utilis pour valuer les habitudes dhyginebuccale des parents. Un modle comportementalparent-enfant a t test par le programme LISREL(relations structurelles linaires).

Rsultats.

Il y avait une corrlation significativeentre DT et ORI-C (

r

= 0,168;

p

< 0,01). Une cor-rlation a t retrouve entre ORI-C et les habitudesde sant buccale des enfants (OHB-C) (OHB-C)(

r

= 0,182;

p

< 0,01). OHB-C tait significativementassoci HU-DBI (

r

= 0,251;

p

< 0,001). Le modlesuppos aprs quelques rvisions tait reliable auxdonnes data (

2

= 1,3,

df

= 6,

p

= 0,97; Indicedadquation = 0,999). Les habitudes de santbuccale des parents avaient galement un effet directsur les habitudes de sant buccale des enfants(

p

< 0,001). Les habitudes de sant buccale desenfants affectaient leurs DT par leur effet sur ltatde sant gingivale. Les habitudes de sant buccaledes parents avaient aussi un effet significatif directsur les DT de leurs enfants (

p

< 0,05). Les habitudesde sant buccale des parents affectaient les habit-udes de sant buccale de leurs enfants (

p

< 0,001).Le grade des enfants affectait la fois le DT et leurshabitudes de sant buccale.

Conclusions.

Les habitudes de sant buccale desparents pourraient avoir une influence directe sur lasant gingivale et les caries de leurs enfants et/ou



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indirecte travers leurs effets sur les habitudes desant buccale de ceux-ci.

Zusammenfassung.

Ziele.

Untersuchung der Wech-selbeziehung zwischen elterlichem Mundgesund-heitsverhalten und dem Mundgesundheitszustanddes Kindes.

Methoden.

Die Stichprobe umfasste 296 Elternpaare(Mutter oder Vater) und deren Kinder an einerGrundschule in Hiroshima. Die Untersuchung derKinder erfolgte nach WHO-Kriterien aufgeschlsseltin karise Zhne (DT) und Zhne mit Restaurationen(FT). Der Oral Rating Index fr Kinder (ORI-C)wurde zur Untersuchung der Gingiva herangezogen.Das Hiroshima Universitt Dental Behaviour Inven-tory (HU-DBI) wurde benutzt zur Feststellung desMundgesundheitsverhaltens der Eltern.

Eine Eltern-Kind-Verhaltensmodell wurde mit demLISREL Programm getestet.

Ergebnisse.

Es zeigte sich eine signifikante Korre-lation zwischen DT und ORI-C (

r

= 0.168;

p

< 0.01)und zwischen ORI-C und OHB-C (

r

= 0.182;

p

< 0.01)sowie zwischen OHB-C und HU-DBI (

r

= 0.251;

p

< 0.001). Das angenommene Modell war nacheinigen nderungen vereinbar mit den Daten (

2

= 1.3,df = 6,

p

= 0.97; Goodness of Fit Index = 0.999).Das Mundgesundheitsverhalten der Eltern beein-flusste das Mundgesundheitsverhalten der Kinder(

p

< 0.001). Das Mundgesundheitsverhalten derKinder beeinflusste den DT-Wert durch den Effektauf die Gingiva. Das Mundgesundheitsverhalten derEltern hatte einen signifikanten direkten Einfluss aufden DT-Wert ihrer Kinder (

p

< 0.05). Die Klassen-stufe beeinflusste sowohl DT als auch das Mundge-sundheitsverhalten der Kinder.

Schlussfolgerungen.

Das elterliche Mundgesund-heitsverhalten knnte die Gingivagesundheit sowieKariesentstehung direkt beeinflussen oder indirektber das Mundgesundheitsverhalten der Kinder.

Resumen.

Objetivo.

El objetivo de este estudio fueel de examinar las relaciones simultneas entre lasconductas sobre la higiene oral de los padres y elestado de salud oral de sus hijos/as en edad escolar.

Mtodos.

Los sujetos comprendan 296 parejas depadres (madre o padre) y sus hijos en una escuelaelemental de Hiroshima. El examen dental de losnios se realiz usando el criterio diagnstico decaries de la Organizacin Mundial de la Salud(OMS) para dientes cariados (DC) y dientes obtura-dos (DO). Se utiliz el Indice de valoracin oral

para nios (ORI-C) para examinar la salud gingival.Se utiliz el Inventario de conducta oral de la Uni-versidad de Hiroshima (HU-DBI) para analizar lasconductas sobre salud oral de los padres. Se probun modelo de comportamiento padre-hijo a travsdel programa de las relaciones lineales estructurales(LISREL).

Resultados.

Exista una correlacin significativaentre DC y ORI-C (

r

= 0,168;

p

< 0,01) Se encontrcorrelacin entre ORI-C y Comportamiento sobrehigiene oral en los nios (OHB-C) (

r

= 0,182;

p

< 0,01) El OHB-C se asoci significativamentecon el HU-DBI (

r

= 0,251;

p

< 0,001)El modelo hipottico, prob ser consistente con

los datos, despus de algunas revisiones (

2

= 1,3;do = 6;

p

= 0,97; Indice de Bienestar = 0,999) Laconducta sobre la salud oral de los padres afectabala conducta sobre la salud oral de sus hijos(

p

< 0,001). La conducta sobre salud oral de los niosafectaba su DO y tambin a los niveles de saludgingival. Las conductas de salud oral de los padrestambin tenan un efecto directo sobre el DO de sushijos (

p

= 0,05). El grado de los nios afectaba tantoa su DO como a su conducta de higiene oral.

Conclusiones.

La conducta sobre la higiene oral delos padres puede influir en la salud gingival y cariesdental de sus hijos directa o indirectamente a travsde sus efectos en la conducta de higiene oral de sushijos.

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Influence of Parents’ Oral Health

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