Evaluation of Tooth Brushing Habits in Preschool Children – A Cross-Sectional Survey

Introduction

Early childhood caries (ECC) is a significant chronic disease of childhood and a public health problem of concern. A systematic review documenting the prevalence of ECC in the Indian population reported an overall prevalence of ECC in India to be 49.6%.¹ American Academy of Pediatric Dentistry (AAPD) in its policy statement on ECC stresses the importance of early preventive practices in reducing the risk of ECC in children, thereby reducing the burden on children, the family, and society. It states that the current best practice to reduce the risk of ECC includes twice-daily brushing with fluoridated toothpaste for all children in optimally-fluoridated and fluoride-deficient communities.²

A prospective cohort study reported the prevalence of caries at the age of five years to be significantly associated with tooth brushing less than twice daily during the pre-school years as well as with difficulties to perform the procedure.³ Khan IM et al., (2021) reported a significant association between pre-schooler’s tooth brushing behaviour and their oral health (gingival health and dental caries status).⁴ A systematic review and meta-analysis on the effect of tooth brushing frequency on dental caries established that infrequent tooth brushing increases the risk of incidence or increment of new carious lesions and this effect was observed to be more pronounced in the deciduous than in permanent dentition.⁵ Thus it is of prime importance to establish proper tooth brushing habits at an early age in children. Adoption of proper and consistent tooth brushing habits early in life will help in establishing the same in their adulthood.

Therefore, this study aimed to understand and assess the tooth brushing habits of preschool children in Bengaluru city, Karnataka. Understanding the tooth brushing habits of children will help us perceive the extent to which appropriate techniques and methods are followed and the level of supervision and involvement of the caregiver during tooth brushing.

Materials and Methodology

This cross-sectional survey was conducted among parents of preschool children chosen from seven randomly selected preschools in the city of Bengaluru, Karnataka, India. Ethical clearance for the study was obtained from the Institutional Review Board, Sri Rajiv Gandhi College of Dental Sciences and Hospital (SRGCDS/2022/369/B). Permission to conduct the study was obtained from the concerned authorities of the selected preschools. 

Sample size estimation

Based on the probability that approximately 50% of the preschool children (p=0.50) follow adequate tooth brushing behaviours and cooperative to tooth brushing habits as per the previous literature, with δ (Margin of Error) =0.10 and Q=1-P, N was calculated as 96.04, at 95% confidence interval. It was rounded off and the sample size was determined as 100.

Materials and Methods

A pre-validated and pre-tested questionnaire regarding the tooth brushing habits and behaviour of children along with an informed consent form were distributed among parents of one hundred and twenty-seven preschool children. An information sheet with a detailed description of the study was also provided to the parents.

The self-administered questionnaire used in this study consisted of two sections. The first section included questions related to the child’s and parent’s demographic details. The second section included questions concerning tooth brushing habits in children. A total of one hundred and two responses were received from parents of preschool children. The data collected was compiled and a master file was created in a Microsoft Excel sheet and statistical analyses were performed using Statistical Package for Social Science (SPSS version 22.0) software.

Statistical analysis

Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 (Armonk, NY: IBM Corp.,) was used to perform statistical analyses. The Chi-Square Goodness of Fit test was used to compare the distribution of the responses among the participants (parents) for the study questionnaire. The Chi-Square test was used to compare the responses to the questionnaire based on the socioeconomic status (SES) and education levels of the child’s parents. The level of significance was set at p <0.05.

Results

The mean age of the preschool children included in the study was 4.7 years, while the mean age of the fathers was 35.21 years, and that of the mothers was 30.34 years. Of the 102 children included, 61% were girls while 39.2% were boys. About 62% of the mothers of these preschool children had a college education compared to 52% of fathers. Other demographic details showed that 53% of the population belonged to the middle class, 43% belonged to the lower class and 4% belonged to the upper class according to the modified Kuppuswamy scale.⁶ Demographic details are depicted in table 1. 

Based on the responses to the questionnaire, it was noted that 60% of the primary caregivers introduced tooth brushing to their children from 6 months to 1 year of age which coincided with the time of eruption of the first tooth in the oral cavity. Tooth brushing was primarily introduced by mothers (95%) in this sample of pre-schoolers.

The entire study population used a toothbrush for cleaning their child’s teeth. However, 15.7% of the caregivers mentioned that their child shares the toothbrush with siblings or other family members. The data also showed that the toothbrushes of 44% of the pre-schoolers were changed every 2-3 months, 38% changed it every month, 19% changed it once their bristles fray out and 2% haven’t changed their toothbrush yet. Around 98% of the pre-schoolers in the present study used toothpaste and this was introduced between 6 months to 1 year in 52% of the population. Around 54% of the children used toothpaste with fluoride, 25% used toothpaste without fluoride and 27% of the parents were unaware of the type of toothpaste being used for their children. Around 58% of the participants reported using a pea-sized amount of toothpaste to brush their child’s teeth, while 31% used half the length.

Regarding the frequency of tooth brushing in children, 61% were noted to brush their teeth once a day, 38% brushed their teeth twice a day and 1% brushed more than once a day. It was also observed that 58.8% of the primary caregivers brushed their teeth only once a day. Pertaining to the duration of tooth brushing, only 18% of the preschool children brushed their teeth for the recommended time of 2-3 minutes. The study also showed that the majority of the population (61%) did not use any other oral hygiene aids apart from tooth brushing.

When enquired on who performs the tooth brushing for the child, it was found that 59% of the children brushed their teeth on their own, 31% of children brushed their teeth under adult supervision and only 10% of the primary caregivers brushed their child’s teeth. 52% of the population reported that they did not have adequate time to brush their child’s teeth twice daily. A large section of parents (66%) opined that their child does not like their teeth being brushed and therefore is difficult to perform brushing twice daily. Also, a greater part of the study population, of around 72% agreed that they did not know how to brush their child’s teeth.

While all the parents agreed that it was important to brush their child’s teeth, it was found that 73% of the parents did not receive any information or education pertaining to the maintenance of oral hygiene in their children.

Discussion

This cross-sectional survey was conducted among parents of preschool children to understand and assess the tooth brushing habits of these young children. There is decisive evidence that tooth brushing is associated with lower levels of caries, Streptococcus mutans levels, and better oral health status and is also a predictor of tooth brushing habits in later childhood and adulthood.^3,7 Therefore it becomes important to understand the tooth brushing habits and behaviours in these young children.

It was noted that mothers are the primary facilitators of oral hygiene in preschool children included in the present study. This finding is in accordance with the reports of Khadri FA (2010) et al.,⁸ Blinkhorn AS (1980),⁹ Mohebbi SZ et al. (2008),⁷ which emphasize the role of the mother in introducing and facilitating oral hygiene in children. This study also elicited that the entire population used a toothbrush to maintain their oral hygiene and around 15% however shared their toothbrush with other family members. 

It was alarming to note that majority of the children (61%) brushed their teeth only once a day, while 38% brushed their teeth twice a day and 1% brushed more than once a day. A positive correlation between the frequency of tooth brushing among children and the primary caregivers was observed with around 58% of the parents brushing their teeth only once daily (p <0.001). Similar results were reported by Okada M (2002) et al.,¹⁰ Mohebbi SZ (2008) et al.⁷ indicating the influence of oral health behaviours of parents on children. We also found no significant association between the frequency of oral cleaning and the level of education, or socioeconomic status of parents indicating the lack of emphasis on the child’s oral health care in the whole community.

As per the AAPD’s policy statement on Early childhood caries, tooth brushing should be performed for children by a parent twice daily. Mohebbi SZ (2008) et al.,⁷ in their study recommended the performance of toothbrushing in children by adults rightly pointing at the lack of dexterity and cognition required for adequate cleaning until approximately six years of age. 

In the present study, only 10% of the parents brushed their child’s teeth, 31% of children brushed under adult supervision, while 59% of children brushed on their own. This indicates a serious inadequacy in the maintenance of oral hygiene in these young children. It was also observed in our study that children of mothers with no formal education and low SES brushed their teeth on their own without any help or supervision from their parents. The plausible reasons for this general lack of performance or supervision of brushing in children by adults could be due to the parental inability to provide individual attention, working mothers, large families or inadequate awareness.

The common reported problems by parents in brushing their child’s teeth in the present study were, not having enough time, the child’s disinterest in brushing the teeth and parental lack of knowledge on child’s tooth brushing. It is not surprising that parents lacked knowledge on tooth brushing given that 73% of parents in the present study reported that they did not receive any information on how to maintain oral hygiene in their children.

It is interesting to note that 100% of the parents who participated in the present study agreed that it is important to maintain good oral hygiene in their children. However, this positive attitude of parents towards tooth brushing and oral hygiene has not translated into practice. This could be due to the lack of in-depth knowledge on the aspects of tooth brushing to be observed in children.

Before deriving conclusions from the present study, it is important to consider its limitations. The obvious limitation was the smaller sample size and thus the extrapolation of the study findings to the entire population must be cautiously done. Secondly, the social desirability response bias, a limitation of self-report studies also must be considered.

Conclusion

It is evident from the literature that simple oral hygiene methods such as brushing twice daily with a fluoridated dentifrice can help reduce caries in children. Since parents, especially mother plays a significant role in the maintenance of oral hygiene in preschool children, it becomes imperative that they are equipped with adequate knowledge to maintain healthy oral hygiene in their children. Prenatal education of expectant parents, community-based early childhood education programs and professional advice from dental professionals and paediatricians regarding the oral hygiene maintenance and its importance will help in substantial improvement of oral and general health of the younger generation.

Conflict of Interest

None