Oral health knowledge, attitude and practice among parents of children with craniofacial syndromes

3.1 The socio-demographic background of parents

A total of 44 parents of children with CS registered at UMMC were approached for this study. However, eight parents gave no response, one withdrew and five parents of children that were not diagnosed with craniofacial disorders were omitted. Hence, only 30 parents of children with CS were able to participate in this study. An additional 30 parents with normal children that matched the age and gender of the study group were used as controls. Fig. 1 depicts the summary of the socio-demographic background of the parents involved. The participants of our study were mainly mothers (73.3%). Parents of children with CS were mostly Chinese (46.7%) whereas parents of other children in the control group were mostly Malay (86.7%). The mean age (and standard deviation) of the mothers and fathers of children with CS were 39.3 (±6.8) years and 43.21 (±8.4) years, respectively. The mean age (and standard deviation) of mothers and fathers in the control group were 36.9 (6.02) years and 39.1 (8.3) years, respectively. The mean age and standard deviation of mothers of children with CS are comparable. On the other hand, the mean age of fathers of children with CS was slightly higher than that of fathers in the control group with relatively equal standard deviations. Most of the parents had tertiary education and came from the middle 40% group (M40) of the Malaysian household class; their monthly household income ranged from RM4851 to RM10,970. Some of the subsections were short of one sample due to irretrievable data (such as death). No statistical significance was detected between the control and test groups (p > 0.05) with this respect.

Fig. 1.Socio-demographic background of parents of children with craniofacial syndromes and children in the control group.

3.2 Socio-demographic background of children with CS

Fig. 2 presents a summary of the children with craniofacial disorders. We found that more than half of the children in our study were girls (56.7%) and were aged 5 years and below (53.3%). The mean age of the children was 6.0 years with a standard deviation of 3.6; these children were mostly affected by Apert syndrome (26.67%) followed by Crouzon (23.3%) and Pfeiffer syndrome (13.3%).

Fig. 2.Socio-demographic background of the children with craniofacial syndromes (the test group).

3.3 Knowledge of oral health

Both groups of parents had a relatively similar depth of knowledge on oral health; answers to only two of the 12 questions assessed were significant when compared between the two groups (p < 0.05). These two questions were regarding the definition of dental plaque and its relationship to caries; we discovered that parents in the control group scored higher (73% and 77% respectively). In contrast, a lower percentage of parents of children with CS were able to answer these questions correctly (47% and 50% respectively) (Table 1).

Both groups of parents failed to acknowledge that dental caries were transmissible with each group scoring less than 30%. With regards to the causes of dental caries, both groups were unaware that crowding and irregular tooth morphology, such as pits and fissures, could increase the risk of caries. Most of these parents were well-equipped with basic knowledge relating to toothbrushing, the types of bristles to be used and the role of fluoride.

3.4 Attitude

Generally, most parents from both groups had a positive attitude towards oral health with a cumulative percentage of 70% and 80% respectively. The results obtained for each statement are illustrated in Fig. 3. A portion of the parents of children with CS (26.7%) were unconcerned if they saw changes in the tooth color of their child. In addition, 23.3% of these parents believed that primary teeth were not important as compared to permanent teeth. In contrast, the control group (93.33%) showed a more positive attitude towards the importance of primary teeth. However, these differences were not statistically significant (p > 0.05) when compared between the two groups.

Fig. 3.Attitude of parents of children with craniofacial syndromes and the control group towards their children.

3.5 Practice

With regards to practice, we assessed the relationship between parental oral health knowledge and the actual practice of their children. This was to identify whether the parents had their children practice what they preached. Of the 67% of parents of children with CS who acknowledged that toothbrushing should be performed twice daily, only 75% of their children practiced the correct frequency. In contrast, 90% of parents in the control group knew the correct toothbrushing frequency; however, only 70% of their children practiced this strategy (Table 2).

When asked about the transmissibility of dental caries, 23% of parents of children with CS were able to answer the question correctly; of these parents, 57% of them blew on or shared their utensils with their children during feeding regardless. Similarly, 27% of parents in the control group were aware that dental caries was transmissible, yet 63% of them still blew on or shared their utensils with their children during feeding.

In total, 53% of parents of children with CS knew that they should take their child to their dentist every six months. However, only 63% of these parents practiced the correct frequency. In contrast, of the 77% of parents in the control group who knew they should take their child to the dentist every six months, only 39% did so.

4.1 Knowledge

Our study revealed that parents from both groups were unaware that irregular tooth morphology can retain plaque and increase susceptibility to caries, particularly in molars where pits and fissures are present. This is especially worrying as the first molars are the earliest permanent dentition to erupt into the oral cavity [8]. Occlusal surfaces of the first permanent molars have been reported to be most likely to be diagnosed with caries within a short period of time after eruption due to high levels of plaque accumulation. This could be due to the lack of awareness amongst parents regarding the emergence of such teeth; hence their children’s oral hygiene was overlooked [9]. Irregular tooth morphology can serve as a reservoir for bacteria to metabolize dietary sugars to produce organic acid; locally, this creates a low pH and subsequently causes demineralization of the tooth surface [10]. Thus, clinicians have been taking precautionary means over the years to abate this problem via the application of fissure sealants and fluoride varnish as soon as these teeth have erupted. Both groups of parents did not know that crowding is more susceptible to dental caries. In these cases, ineffective cleaning, especially in tight proximal contact areas, may lead to ineffective oral hygiene [11], thereby leading to the formation of proximal caries.

Dental caries has been reported to be able to transmit between individuals via saliva with Streptococcus mutans as the main etiological agent [12]. From our study, more than 70% of parents from both groups were unaware of this fact. This finding is similar to a study reported by Nassar et al. [13] in which a high percentage of parents in their study kissed or shared utensils with their child. To break the chain of caries transmission, parents and caregivers must avoid sharing utensils or blowing on food prior to feeding their children.

4.2 Attitude

Tooth discoloration has a broad array of causes. Some cases represent an indicator of tooth destruction, such as dental caries and microbial involvement; this leads to a black discoloration [14]. We found out that a quarter of parents of children with CS were not worried if there were any changes to their color of their children’s teeth. This may be due to the fact that they are already preoccupied with multiple commitments for their child, namely medical follow-ups, speech therapy or psychological support; thus, oral health seems to be the least of their priorities [1]. A different study has shown that the children themselves, especially girls, are more disapproving of their tooth discoloration [15].

With regards to the importance of primary teeth as compared to permanent teeth, some respondents believed that the primary teeth are not as important as the latter; this was a similar discovery to a study reported previously by Jain et al. [6]. This finding is especially daunting because untreated carious primary teeth can cause harmful effects on a child’s well-being. Their quality-of-life can be affected due to pain, along with acute and chronic infection, thus resulting in sleep disturbances [16], thereby affecting their performance in school. In contrast, parents in the control group performed well for this question (93.33% of those surveyed).

4.3 Practice

It is important to note that children with CS have different oral manifestations when compared to other children. The common presentations include retrognathic mandibles, limited mouth opening and hypodontia. Children with Apert syndrome may have severe crowding, delayed eruption and an anterior open bite [17] whereas Crouzon syndrome may manifest with impacted and malformed roots and crowns [18]. Thus, we need to be mindful of the challenges that these children may face when trying to maintain good oral hygiene.

There is an international consensus that brushing twice daily is recommended by most practitioners as it helps in effective plaque control [19]. However, our study found that a minority of the parents of children with CS claimed that their children only brushed once daily, despite knowing the correct frequency. This may be because these children have small jaws the small jaws which limit their mouth opening, thus impeding them from brushing their teeth properly. In addition to this, children with craniofacial syndromes who have undergone surgeries may face postoperative complications such as hypoplastic maxillae, disfigured dental arches and oronasal fistula [2]. These features would require a separate approach for them to achieve a disease-free oral cavity as compared to normal children. For instance, the presence of an oral fistula may cause the regurgitation of water during toothbrushing, thus leading to inconvenience for both the child and parent when attempting to practice good oral hygiene.

Some children with CS that have issues with their psychomotor and intellectual skills can further aggravate the situation especially when parents are attempting to gain their cooperation and focus during tooth brushing. This dampens the ability and motivation of both parties to apply correct oral hygiene practices. Therefore, parents are responsible to work hand-in-hand with clinicians via oral health education during dental visits.

Fluoride has been proven to bring a plethora of advantages to our teeth, especially in reducing the prevalence of caries by increasing remineralization and reducing demineralization of the enamel [20]. In the present study, we found that all parents had incorporated a fluoride source in their daily schedule.

Despite acknowledging that dental visits should be undertaken every 6 months, 37.5% of the parents of children with CS were irregular attendees. This correlates with a study conducted by Al-Oufi and Omar [21] which revealed that most mothers felt that regular dental visits are not essential. A potential cause to this finding can be explained by Chi Adam et al. [1], who discovered that parents of children with CS experience financial restraints from the numerous medical follow-ups they need to take their child to. In fact, these parents were mostly committed to dual occupations and do not have much time to engage their children with dental appointments. Furthermore, the emergence of the COVID-19 pandemic led the parents to refrain from going outdoors as a safety precaution.

The primary limitation of this study is the small sample size; this was due to its low incidence in Malaysia (0.003%) [1]. Therefore, when non-statistically significant outcomes were identified, it was not evident whether this was due to a true non-statistically significant outcome or whether there was inadequate power (from the small number of samples). In addition, these samples were obtained from a single center via Google Forms rather than physical forms; consequently, potential selection bias may have occurred. Furthermore, the data related to the practice section were based on only the respondents that had answered correctly in the knowledge section to match the objective of the study. Thus, future studies can improve these aspects for better data representation and research outcomes.