Influence of socioeconomic status
Social class
The relationship between parents’ social status and children’s dental health has been demonstrated in numerous studies. Many studies in Western industrialized countries have also shown a relationship between on the one hand, the parents’ dental health status, dental knowledge, and dental care habits and on the other, the prevalence and incidence of dental caries in their children (Martinsson, 1973; Martinsson and Petersson, 1972). For example, Martinsson and Petersson (1972) found a much higher percentage of edentulous parents among children with high caries experience than children with low caries experience. Asher et al (1986) reported a significant correlation between parents’ dietary carbohydrate intake and the oral health of the dependent child.
Beal (1989) has detailed risk factors contributing to higher caries prevalence in children of low socioeconomic background. These include infant-feeding practices conducive to nursing bottle caries, lesser parental involvement in hygiene practices, and a much lesser parental knowledge of, and involvement in, topical and supplementary fluoride regimens.
In the US caries prevalence in schoolchildren in relation to the educational level of the children’s mothers was evaluated. Because the area had fluoridated drinking water, caries prevalence in the children was generally low; nevertheless, there was still significantly less caries in children with well-educated mothers than in those whose mothers had less education. In the 3-year longitudinal study in almost 500 US schoolchildren, discussed earlier, Burt et al (1988) failed to find any correlation between frequency of intake of sugary products and children who developed 0 or
more than 2 approximal carious lesions. Social factors (parents’ income and educational level) had a highly significant relationship with caries incidence, but these factors did not confound any of the relationships with dietary factors.
In a longitudinal study, Grytten et al (1988c) examined the influence of various social and behavioral variables on, and the predictability of, caries experience in early childhood. Data were collected when the children were 6, 18, and 36 months old, through parental questionnaires and, at 36 months of age, clinical examination. Caries experience at 36 months showed a statistically significant association with the child’s sugar consumption as well as with the mother’s dental health, dental care attendance pattern, and level of education. However, when a multivariate model was constructed of predictors that bivariately had shown a statistically significant association with caries experience, only the number of missing teeth in the mother was significantly associated with caries experience, and the explained variance of the dependent variable was low.
Primosch (1982) investigated the effect of family structure on dental caries experience of children, in an attempt to identify those at greatest risk. Multiple linear regression analysis showed that none of the selected variables in family structure was sensitive enough to predict children at greatest risk. Maternal age at marriage and family size, however, seemed to show the most promise for predictive value. Comparison of the family structure of children with high and low caries experience disclosed the following:
1. Children of parents who married young (mother younger than 20 years and father
younger than 22 years) had significantly greater caries prevalence.
2. Children born to mothers younger than 23 years and fathers younger than 28 years
were also more susceptible to caries.
3. Children with birth ranks or family size at either extreme (one child or more than
three children) were significantly more susceptible to caries.
4. Age-span differences between siblings had little effect on the caries experience of
the subject.
The predictive power of a number of sociologic and behavioral variables was
investigated by Poulsen (1988) in a study of the public child dental service in
Denmark. A multivariate logistic regression analysis, expressing caries risk by the
odds ratio, showed high risk of caries (Table 11) in the following cases:
1. Learning disability in the child
2. A high level of pocket money spent on sweets
3. Little support from family
4. Little or no discussion about dental health
5. Negative attitudes toward dental health
6. Negative parental attitudes toward a healthy diet
7. Low educational level
8. Economic pressures in the family
The sensitivity was 66%, the specificity 80%, and the predictive power 71%.
However, when sociologic variables as well as epidemiologic variables were included
in the analysis, sensitivity increased to 95%, specificity to 91%, and the predictive
power to 91%. This study clearly shows the value of integrating family health support
and living conditions in caries-predictive models. The validity and practical
application of these promising findings warrant testing on another pediatric
population.
Ethnicity
Several studies have shown highly significant caries differences between racial groups
(eg, Clerehugh and Lennon, 1986). In the English city of Coventry, Paul and
Bradnock (1986) found the dental health of Asian children to be considerably poorer
overall than that of indigenous children. In Sweden, Widstrom and Nilsson (1986)
found that the proportion of each immigrant group who visited a dentist was
significantly smaller than the corresponding proportion of Swedes, and extractions,
endodontic procedures, and dentures were more common in all the immigrant groups.
In Britain, the Dental Strategy Review Group (DHSS, 1981) recommended that the
community dental service look to the requirements of “special needs groups.” Gelbier
and Taylor (1985) stated that young Asian children, and possibly children of other
ethnic minorities, are dentally disadvantaged through language, primary socialization,
and the lack of appreciation of minority cultures and needs among the ethnic majority.
There is extensive evidence of dietary differences between Asians and other groups
within the community, not only resulting from different cultural backgrounds but also
associated with social deprivation and communication problems.
In a study of 5-year-old Asian schoolchildren in an area of Britain with multiple
deprivation (Bedi, 1989), three distinct dental high-risk groups were identified: (1)
children of Muslim, English-speaking mothers; (2) children of Muslim, non-Englishspeaking
mothers; and (3) children of non-Muslim, non-English-speaking mothers. In
West Birmingham, where Asian children were shown to have a rate of decayed,
missing, or filled teeth nearly twice as high as that of white children, special
programs, tailored to meet the needs of special groups, have been recommended
(Bradnock et al, 1988).
Apart from language and cultural problems and an often low standard of education
among immigrants, emigration disrupts traditional eating habits and leads to exposure
to new foods. Studies consistently show that breakfast and snacks, the meals with the
least symbolic importance, are the first to change. Therefore, immigrants with poor
standards of oral hygiene and an associated irregular use of fluoride toothpaste are at
high risk of developing caries when they come to Western countries, and this can
partly be attributed to dietary changes.
The role of the parents’ immigrant background on caries development in infants and
toddlers was recently highlighted in the longitudinal studies by Wendt et al (1994)
and Wendt and Birkhed (1995), mentioned earlier. The aim of the initial studies was
to describe oral hygiene factors in infants and toddlers living in Sweden, with special
reference to caries prevalence at 2 and 3 years of age and to immigrant status. The
study was designed as a prospective, longitudinal study starting with 671 children,
aged 1 year. At 3 years, all the children were offered a further examination. A total of
298 children, randomly selected from the original group, were also examined at 2
years. The accompanying parent was interviewed about the child’s oral health habits.
Compared to the children with caries at age 3 years, the caries-free children had had
their teeth brushed more frequently at 1 and 2 years of age, had used fluoride
toothpaste more often at 2 years of age, and had a lower prevalence of visible plaque
at 1 and 2 years of age. Immigrant children had had their teeth brushed less
frequently, had used fluoride toothpaste less often, and had a higher prevalence of
visible plaque at 1 year of age than did nonimmigrant children. Seventy-eight percent
of 3-year-old nonimmigrant children were caries free, compared to only 50% of the
children of immigrant parents. The authors concluded that early establishment of good
oral hygiene habits and regular use of fluoride toothpaste seem to be important for
achieving good oral health in preschool children. These goals are achieved less
commonly in children of parents with an immigrant background (Wendt et al, 1994).
The purpose of the second study was to describe dietary habits in infants and toddlers
living in Sweden, with special reference to caries prevalence at 2 and 3 years of age
and to immigrant status. The study was designed as a prospective, longitudinal study
starting with children aged 1 year. At 3 years, all children were offered a further
examination. The accompanying parent was interviewed about the child’s dietary
habits.
Children with caries at 2 and 3 years of age and immigrant children, at the age of 1
year, had consumed caries-risk products, had been fed at night, and had been bottlefed
with sweet drinks more often than caries-free 2 and 3 year olds and nonimmigrant
children. Although a great variation in dietary habits in infants and toddlers was
recorded, the use of sugar-containing products is widespread in Sweden even in early
childhood (Wendt and Birkhed, 1996). In contrast to many immigrant parents,
however, almost all nonimmigrant parents of today’s infants and toddlers are educated
at least to matriculation level and have had access to regular preventive programs
since birth.
With respect to ethnic minorities, the main problems are therefore not the prediction
and identification of high risk but the lack of programs tailored to meet their special
needs. Few studies of this kind have been conducted in developing countries; these
would be of great interest, because the particular parental characteristics associated
with children’s caries experience are bound to differ in different cultures.
