Analysis of Race and Ethnicity, Socioeconomic Factors, and Tooth Decay Among US Children

Importance

While large oral health disparities remain by race and ethnicity among children, the associations of race, ethnicity, and mediating factors with oral health outcomes are poorly characterized. Identifying the pathways that explain these disparities would be critical to inform policies to effectively reduce them.

Objective

To measure racial and ethnic disparities in the risk of developing tooth decay and quantify relative contributions of factors mediating the observed disparities among US children.

Design, Setting, and Participants

This retrospective cohort study used electronic health records of US children from 2014 to 2020 to measure racial and ethnic disparities in the risk of tooth decay. Elastic net regularization was used to select variables to be included in the model among medical conditions, dental procedure types, and individual- and community-level socioeconomic factors. Data were analyzed from January 9 to April 28, 2023.

Exposures

Race and ethnicity of children.

Main Outcomes and Measures

The main outcome was diagnosis of tooth decay in either deciduous or permanent teeth, defined as at least 1 decayed, filled, or missing tooth due to caries. An Anderson-Gill model, a time-to-event model for recurrent tooth decay events with time-varying covariates, stratified by age groups (0-5, 6-10, and 11-18 years) was estimated. A nonlinear multiple additive regression tree-based mediation analysis quantified the relative contributions of factors underlying the observed racial and ethnic disparities.

Results

Among 61 083 children and adolescents aged 0 to 18 years at baseline (mean [SD] age, 9.9 [4.6] years; 30 773 [50.4%] female), 2654 Black individuals (4.3%), 11 213 Hispanic individuals (18.4%), 42 815 White individuals (70.1%), and 4401 individuals who identified as another race (eg, American Indian, Asian, and Hawaiian and Pacific Islander) (7.2%) were identified. Larger racial and ethnic disparities were observed among children aged 0 to 5 years compared with other age groups (Hispanic children: adjusted hazard ratio [aHR], 1.47; 95% CI, 1.40-1.54; Black children: aHR, 1.30; 95% CI, 1.19-1.42; other race children: aHR, 1.39; 95% CI, 1.29-1.49), compared with White children. For children aged 6 to 10 years, higher risk of tooth decay was observed for Black children (aHR, 1.09; 95% CI, 1.01-1.19) and Hispanic children (aHR, 1.12; 95% CI, 1.07-1.18) compared with White children. For adolescents aged 11 to 18 years, a higher risk of tooth decay was observed only in Black adolescents (aHR, 1.17; 95% CI, 1.06-1.30). A mediation analysis revealed that the association of race and ethnicity with time to first tooth decay became negligible, except for Hispanic and children of other race aged 0 to 5 years, suggesting that mediators explained most of the observed disparities. Insurance type explained the largest proportion of the disparity, ranging from 23.4% (95% CI, 19.8%-30.2%) to 78.9% (95% CI, 59.0%-114.1%), followed by dental procedures (receipt of topical fluoride and restorative procedures) and community-level factors (education attainment and Area Deprivation Index).

Conclusions

In this retrospective cohort study, large proportions of disparities in time to first tooth decay associated with race and ethnicity were explained by insurance type and dental procedure types among children and adolescents. These findings can be applied to develop targeted strategies to reduce oral health disparities.

Cost-effectiveness of Dental Workforce Expansion Through the National Health Service Corps and Its Association With Oral Health Outcomes Among US Children

Importance

Despite considerable efforts to improve oral health for all, large disparities remain among US children. A dental professional shortage is thought to be among the determinants associated with oral health disparities, particularly for those residing in underserved communities.

Objective

To evaluate the cost-effectiveness of expanding the dental workforce through the National Health Service Corps (NHSC) and associations with oral health outcomes among US children.

Design, Setting, and Participants

A cost-effectiveness analysis was conducted to estimate changes in total costs and quality-adjusted life years (QALYs) produced by increasing the NHSC funding for dental practitioners by 5% to 30% during a 10-year period. A microsimulation model of oral health outcomes using a decision analytic framework was constructed based on oral health and dental care utilization data of US children from 0 to 19 years old. Data from the nationally representative National Health and Nutrition Examination Survey (NHANES, 2011-2016) were linked to county-level dentist supply and oral health professional shortage areas (HPSAs) information. Changes in prevalence and cumulative incidence of dental caries were also estimated. Sensitivity analyses were conducted to assess the robustness of results to variation in model input parameters. Data analysis was conducted from August 1, 2021, to November 1, 2022.

Exposures

Expanding dental workforce through the NHSC program.

Main Outcomes and Measures

Changes in total QALYs, costs, and dental caries prevalence and cumulative incidence.

Results

This simulation model informed by NHANES data of 10 780 participants (mean [SD] age, 9.6 [0.1] years; 5326 [48.8%] female; 3337 [weighted percentage, 57.9%] non-Hispanic White individuals) found that when funding for the NHSC program increased by 10%, dental caries prevalence and total number of decayed teeth were estimated to decrease by 0.91 (95% CI, 0.82-1.00) percentage points and by 0.70 (95% CI, 0.62-0.79) million cases, respectively. When funding for the NHSC program increased between 5% and 30%, the estimated decreases in number of decayed teeth ranged from 0.35 (95% CI, 0.27-0.44) to 2.11 (95% CI, 2.03-2.20) million cases, total QALY gains ranged from 75.76 (95% CI, 59.44-92.08) to 450.50 (95% CI, 434.30-466.69) thousand QALYs, and total cost savings ranged from $105.53 (95% CI, $70.14-$140.83) to $508.23 (95% CI, $598.91-$669.22) million among children residing in dental HPSAs from a health care perspective. Benefits of the intervention accrued most substantially among Hispanic children and children in low-income households.

Conclusions and Relevance

This cost-effectiveness analysis using a decision analytic model suggests that expanding the dental workforce through the NHSC program would be associated with cost savings and a reduced risk of dental caries among children living in HPSAs.

Racial and ethnic disparities in periodontal health among adults seeking dental care in rural North Carolina communities: A retrospective study

BACKGROUND

Population studies consistently demonstrate a greater prevalence of chronic diseases, including oral diseases, among underrepresented minorities. This retrospective study aimed to measure and describe the prevalence and extent of periodontitis among adults seeking dental care within an academic practice-based network in rural North Carolina.

METHODS

This study used de-identified electronic health record (EHR) data from 2011 to 2017 of adult dentate patients (aged ≥30 years) seeking dental care who received a comprehensive periodontal examination at one of nine networked clinical centers. Periodontitis prevalence was calculated using CDC/AAP case definitions, along with extent (%) scores for periodontal parameters. Comparisons focused on age, sex, race, ethnicity, tobacco use, diabetes status, payer or insurance status, plaque scores, and the number of teeth.

RESULTS

EHR data for 10,544 adult patients (60.5% female) indicated 79.8% had some form of periodontitis. This patient population was diverse: 22.6% Black, 4.4% American Indian, and 53.8% White, with 4.8% self-identified as Hispanic. Patients 50 years and older showed greater mean extent scores for clinical attachment levels relative to patients 30 to 49 years. Males exhibited greater periodontitis than females (p = 0.001). Blacks showed significantly (p < 0.001) greater periodontitis prevalence relative to Whites. Hispanics also showed a greater prevalence of periodontitis (p < 0.001) relative to non-Hispanics. Significantly greater periodontitis was also noted for tobacco users (p < 0.001) but not for diabetes or payer status. A multiple logistic regression analysis of periodontitis prevalence confirmed significant associations for periodontitis for age, sex, race, ethnicity, tobacco use, high plaque scores, and the number of teeth (p < 0.001), but not diabetes or payer status.

CONCLUSIONS

The data document that racial and ethnic inequalities in periodontal health occur within the population of adults residing in rural communities in North Carolina and seeking dental care.

Oral Care Knowledge, Attitudes, and Practices of Black/African American Caregivers of Autistic Children and Non-Autistic Children

Oral health is a vital component of overall health. Children from underserved, minoritized populations (i.e., Black/African Americans, autistic children) are at even greater risk for experiencing oral health disparities. This study aims to illuminate the oral health knowledge, attitudes, and practices of Black/African American caregivers of autistic and non-autistic children. Black/African American caregivers of children (4-to-14 years) on the autism spectrum (n = 65) or not on the autism spectrum (n = 60), participated in a survey, with input from literature reviews, interviews, previous research, and reviews by experts. Caregivers demonstrated basic knowledge of oral health with significantly lower scores for caregivers of autistic children. Caregivers care about oral health and would like to increase their knowledge. Significant differences in oral care practices were found between the autistic and non-autistic groups. Caregivers reported they can access dental services with relative ease, including finding their child a dentist, scheduling a dental appointment, and accessing transportation (personal or public) to attend the visit. Black/African American caregivers of autistic children and children without autism seem to have foundational knowledge about oral health and basic practices; however, they are interested in learning more. Therefore, tailored oral health education programs may help mitigate oral health disparities for Black/African American families.

Measuring the quality of dental care among privately insured children in the United States

OBJECTIVE

To examine whether quality of dental care varies by age and over time and whether community-level characteristics explain these patterns.

DATA SOURCE

Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019.

STUDY DESIGN

A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person- and zip code-level factors associated with the quality.

DATA COLLECTION/EXTRACTION METHODS

Continuously enrolled US dental insurance beneficiaries younger than 21 years of age.

PRINCIPAL FINDINGS

Quality was assessed for 4.88 million person-years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0-5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0-5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less-educated populations at the zip code level were associated with the composite score.

CONCLUSION

Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low-performing localities should be explored.

Perspectives on Social and Environmental Determinants of Oral Health

Most oral conditions have a multifactorial etiology; that is, they are modulated by biological, social, economic, cultural, and environmental factors. A consistent body of evidence has demonstrated the great burden of dental caries and periodontal disease in individuals from low socioeconomic strata. Oral health habits and access to care are influenced by the social determinants of health. Hence, the delivery of health promotion strategies at the population level has shown a great impact on reducing the prevalence of oral diseases. More recently, a growing discussion about the relationship between the environment, climate change, and oral health has been set in place. Certainly, outlining plans to address oral health inequities is not an easy task. It will demand political will, comprehensive funding of health services, and initiatives to reduce inequalities. This paper sought to give a perspective about the role of social and physical environmental factors on oral health conditions while discussing how the manuscripts published in this Special Issue could increase our knowledge of the topic.

Development of a secondary school-based digital behaviour change intervention to improve tooth brushing

BACKGROUND

Dental caries in adolescents remains a significant public health problem with few oral health promotion interventions aimed at reducing dental caries in secondary school-aged students. Previous oral health and mobile health (mHealth) research has suggested the need for the development of a school-based behaviour change intervention incorporating a digital component. This study aimed to describe the development process of a behaviour change intervention to improve the oral health of students aged 11-16 years attending secondary schools in the UK.

METHODS

A six-step process was used to develop the complex intervention informed by behaviour change theory and involving students, young people, parents and teachers in the process. The steps were: (1) identifying the target behaviours, namely tooth brushing with a fluoride toothpaste (2) identifying the theoretical basis and developing the causal model (3) reviewing the relevant literature and developing the logic model (4) designing the intervention with young people, parents and school staff (5) specifying the intervention content and (6) translating this content into features of the intervention and piloting.

RESULTS

The resultant intervention included a quality-assured classroom-based session (CBS) (guided by a lesson plan and teaching resources), delivered by school teachers which was embedded within the school curriculum. This CBS was followed by a series of (Short Message Service) SMS texts delivered twice daily to student's mobile telephones with the content, duration and timing of the messages informed by involvement of students and young people.

CONCLUSIONS

An intervention to improve the oral health of secondary school students through improved tooth brushing was rigorously developed based on behaviour change theory and work with young people, parents and school staff. Further research is needed to evaluate the outcomes and processes involved following the delivery of this intervention. BRIGHT Trial Trial Registration ISRCTN12139369.

Motivators and barriers to oral hygiene self-care among adolescents in Malaysia: A qualitative study

OBJECTIVE

Having good oral hygiene self-care, especially a regular toothbrushing habit will promote lifelong oral health. Therefore, understanding the factors that influence an adolescent's oral hygiene behaviour is important in developing effective oral health programmes for this age group. This study aimed to explore the motivators and barriers to adolescents' oral hygiene self-care by exploring the perspectives of secondary school students from three government schools in the state of Selangor, Malaysia.

METHODS

Focus group discussions (FGD) were conducted with Form 2 (14-years-old) and Form 4 (16-years-old) students from selected secondary schools in Selangor using a semi-structured topic guide until data saturation was reached. Data were transcribed verbatim and analysed using framework method analysis.

RESULTS

A total of 10 FGDs were conducted involving 77 adolescents. The motivators for good oral hygiene self-care were appearance, fear of oral disease, consequences of oral disease and past toothache experience. The barriers for oral hygiene self-care were poor attitude towards oral care, lack of confidence in toothbrushing skills, snacking habit and the taste of toothpaste.

CONCLUSION

Understanding the motivators and barriers to adolescents' oral hygiene self-care is the first step in designing effective oral health education messages. The findings from this study can be used as a guide for oral health education programmes and development of materials that fulfil the needs of the adolescent population.

Impact of the Brush Day & Night Programme on Oral Health Knowledge and Behaviour in Children

OBJECTIVES

School-based interventions can establish positive behaviours that reduce the likelihood of oral diseases later in life. The Brush Day & Night (BDN) programme is a 21-day school-based educational programme to promote good oral health behaviours. This study aims to evaluate the effect of the BDN programme on oral health knowledge and behaviour outcomes in children after the intervention as compared to a control group over 24 weeks.

METHODS

This was a superiority cluster randomised trial of children aged 6-12 years from Indonesia (N = 2021) and Nigeria (N = 750). All children were provided with toothpaste and a toothbrush, and the intervention groups (N = 1107 and 439, respectively) received the 21-day BDN programme. Children were followed up at Weeks 3, 8, and 24 after the programme start date and completed a questionnaire addressing the objectives at all timepoints. Improvement in oral health knowledge and behaviour was calculated based on the percentage of positive change in answers and analysed based on a conditional logistic approach for each evaluation timepoint, compared with control, with a 95% CI.

RESULTS

After 24 weeks, Indonesian children following the BDN programme presented with a 30% and 60% additional probability, respectively, of adequate timing of toothbrushing and of being aware of the importance of adequate toothbrushing frequency compared with control. In Nigeria, after 24 weeks, children following the BDN programme had a 92% and 73% higher probability of adequate toothbrushing frequency and of using fluoride toothpaste, respectively, compared with control.

CONCLUSIONS

The BDN programme is effective at improving children's knowledge and behaviour compared with a control population.

Improving understanding about dental health issues in college students

Good oral health has been shown to be an important facet of overall well-being. Optimal oral health is achieved through routine daily self-care, proper diet, and regular prevention visits to a dental professional. Adolescence and early adulthood may be a time where these self-care routines change for a variety of reasons, including newfound independence, changes in one's financial status, or transportation difficulties. Therefore, the aim of this study was to describe the dental health status and behaviors of a sample of college students, as well as identify barriers to oral healthcare. Results from this diverse sample (n = 705, 95% response rate) revealed that nearly a third (31.3%) of the students had a current untreated dental health issue, with the most common barriers reported by these students being cost (n = 92) and lack of time (n = 89). Daily self-care behaviors (brushing and flossing) were more prevalent in the morning rather than evening hours.

The effectiveness of behavioral interventions to improve oral health in adolescents at different periods of follow-up: A systematic review and meta-analysis

BACKGROUND

The aim of this review was to examine the effectiveness of behavioral interventions at different follow-up periods to improve adolescents' oral health.

METHODS

CENTRAL, MEDLINE, EMBASE and other databases were systematically searched. Inclusion criteria were as follows: participants aged 10-19 years old, randomized controlled trials using behavioral interventions, outcome measurements including oral health knowledge, attitudes, practices, and oral health status. For each included study, behavior change techniques (BCT) were identified and the quality and risk of bias assessments obtained. PROSPERO reference: CRD42018090341.

RESULTS

After searching and screening, 17 clinical trials were included in the systematic review. The most commonly used BCTs were behavior health link, information on consequences, and social comparisons. A significant reduction of plaque index was detected (SMD:-0.46; 95 % CI:-0.82∼-0.10) for 3 months and (SMD:-0.71; 95 % CI:-1.08∼-0.33) for 6 months. The reduction of gingival index after 6 months was also significant (SMD:-0.90; 95 % CI:-1.33∼-0.47). Oral health knowledge and oral health-related behavior were also improved after behavioral interventions.

CONCLUSION

There is moderate evidence that behavioral interventions are effective in promoting oral health in adolescents. To establish more evidence-based conclusions, further research should focus on: quality control of interventions, full descriptions regarding the BCT, long-term follow-ups, and behavior change reinforcements.

PRACTICAL VALUE

Given the need of early prevention of oral diseases, well-designed oral health promotion programme are needed to improve behavior and outcome of adolescents' oral health.

Yarning about oral health: perceptions of urban Australian Aboriginal and Torres Strait Islander women

BACKGROUND

Many factors influence how a person experiences oral health and how such experiences may facilitate supportive oral health behaviours. Women in particular face different challenges due to their environment, responsibilities and physiological differences to men. Within Australia, Aboriginal and Torres Strait Islander women are reported to have poorer oral health and are faced with additional barriers to supporting their oral health compared with non-Indigenous women. The objective of this paper is to report the experiences and perceptions of oral health from the perspective of urban, Aboriginal and Torres Strait Islander women.

METHODS

The present data derive from a descriptive study that used yarning circles and face-to-face interviews with women who were mothers/carers of urban, Aboriginal and/or Torres Strait Islander children. This was a qualitative study to investigate the impact of child oral health on families. Participants used the opportunity to share their own personal experiences of oral health as women, thus providing data for the present analyses. Information collected was transcribed and analysed thematically.

RESULTS

Twenty women shared their personal narratives on the topic of oral health which were reflective of different time points in their life: growing up, as an adult and as a mother/carer. Although women are trying to support their oral health across their life-course, they face a number of barriers, including a lack of information and the costs of accessing dental care. The teenage years and pregnancy were reported as important time periods for oral health support.

CONCLUSIONS

To improve the oral health of Indigenous Australian women, policymakers must consider the barriers reported by women and critically review current oral health information and services. Current oral health services are financially out of reach for Indigenous Australian women and there is not sufficient or appropriate, oral information across the life-course.

The Persistence of Oral Health Disparities for African American Children: A Scoping Review

Oral health is an important yet often neglected component of overall health, linked to heart disease, stroke, and diabetic complications. Disparities exist for many groups, including racial and ethnic minorities such as African Americans. The purpose of this study was to examine the potential factors that perpetuate oral health care disparities in African American children in the United States. A systematic search of three literature databases produced 795 articles; 23 articles were included in the final review. Articles were analyzed using a template coding approach based on the social ecological model. The review identified structural, sociocultural, and familial factors that impact the ability of African Americans to utilize oral care services, highlighting the importance of the parent/caregiver role and the patient⁻provider relationship; policy-level processes that impact access to quality care; the value of autonomy in treatment and prevention options; and the impact of sociocultural factors on food choices (e.g., food deserts, gestures of affection). In conclusion, oral health care remains an underutilized service by African American children, despite increasing access to oral care secondary to improvements in insurance coverage and community-based programs.

Look at my pearly white teeth: Exploring adolescents' oral health behavior

Informed by grounded theory, this study explored adolescent oral health behaviors to determine what factors influence them and to develop a substantive theory explaining the social process behind the behaviors identified. Multiple types of data were collected and analyzed simultaneously: demographic and oral health questionnaires, 16 individual interviews, eight small group discussions, field notes, and investigator memoing. Participants were 37 Midwestern adolescents aged 13-18, and most were White or African-American females 14 years of age whose parents had at least a high school education. While more than half reported using mouthwash and brushing their teeth regularly, almost all participants described their behavior in terms of relationships, confidence, and attractiveness rather than health. Top motivators were habits learned as children and the desire to be attractive or "kissable." To reflect teens' understanding of "healthy" as good-looking, and their primary concern not with having healthy teeth but with being attractive to peers, our model of the basic social process of adolescent oral health behavior is called "Look at my Pearly White Teeth." Understanding the actual motivations behind adolescent oral health behavior can help public health administrators develop more effective interventions, especially for teens who did not learn healthy habits as children.

Effect of automated messaging on oral hygiene in adolescent orthodontic patients: A randomized controlled trial

OBJECTIVE

To determine whether automated text messages sent daily to adolescent orthodontic patients improves oral hygiene more than weekly reminders.

MATERIALS AND METHODS

A blinded, prospective, randomized controlled trial was designed to evaluate the effects of automated messages on oral hygiene. Subjects were recruited from patients undergoing orthodontic treatment at the Texas A&M University College of Dentistry, Department of Orthodontics. They were being treated with a variety of fixed full appliances in both arches. Subjects were randomly assigned to either a once-a-week text message group or a daily text message group. There were 52 females and 27 males who were 12 to 17 years of age. Oral hygiene was measured at the beginning of the study and again 8.6 ± 0.9 weeks later.

RESULTS

The daily reminder group (N = 42) had significantly greater improvements in oral hygiene compliance than the weekly reminder group (N = 37). The daily score decreases were 48%, 21% and 19% for the bleeding index (BI), plaque index (PI), and gingival index (GI), respectively. The weekly score decreases were 27%, 14% and 13% for the BI, PI, and GI. There were no sex differences in hygiene changes during the study. The 42% of patients who completed the survey at the end of the study wanted more frequent messages and reported that messages related to decreasing treatment time were the most effective, while those related to oral hygiene were the least effective.

CONCLUSIONS

Daily text messages are more effective at improving oral hygiene than weekly text messages.

Relationship between Problematic Internet Use, Sleep Problems, and Oral Health in Korean Adolescents: A National Survey

We examined the relationship between Problematic Internet Use (PIU), sleep (sleep satisfaction, sleep duration), and experience of oral disease symptoms in Korean adolescents by gender. This cross-sectional study utilized the 6th (2010) Korean Youth Risk Behavior Web-based Survey. Participants comprised 74,980 students from 400 middle schools and 400 high schools nationwide. Among these, 73,238 students from 799 schools (38,391 boys, 34,847 girls, aged 13–18 years) were included in the analysis (inclusion rate = 97.7%). Multiple logistic regression and analysis of moment structures (AMOS) analyses were performed to identify meaningful relationships between the three factors. The “high risk group” of problematic internet usage had increased experience of oral disease symptoms (boys: adjusted odds ratio (AOR) = 1.92, 95% confidence interval (CI) = 1.63–2.28, girls: AOR = 1.98, 95% CI = 1.50–2.63) compared to the general group. Boys who used the Internet for “5–6 h” had a higher risk of oral disease symptoms compared to those who used it for “less than 1 h” (OR = 1.24, 95% CI = 1.01–1.53); however, this difference was not significant in Models II and III. For girls, the risk of 5–6 h of use (Model I: OR = 1.69, 95% CI = 1.40–2.04) was higher than that of the boys. In addition, the difference was significant in Models II and III for girl students who used the Internet for 5–6 h. In subgroup analysis, the high-risk group had a higher odds ratio for mild symptoms of bad breath to severe symptoms such as sore and bleeding gums. In addition, in the path analysis, PIU affected sleep and indirectly affected oral health. Direct and indirect causal relationships between the three factors were confirmed. Therefore, it is important to recognize that PIU can have a detrimental effect on mental, physical, and oral health.

The effectiveness of the Brush Day and Night programme in improving children's toothbrushing knowledge and behaviour

BACKGROUND

Regular twice-daily toothbrushing with a fluoridated toothpaste is widely recommended for schoolchildren. The '21-day Brush Day and Night (BDN) programme' includes an educational approach for children and school staff, with a consistent practice of toothbrushing at school for 3 weeks.

OBJECTIVE

This study aims to evaluate the improvement in oral hygiene knowledge and behaviour in schoolchildren involved in BDN, the sustainability of this after 6-12 months, and if any particular age group was more receptive to it than others.

MATERIALS AND METHODS

Ten countries and 7,991 children, 2-12 years old, participated in this longitudinal study, with two BDN interventions at the beginning and 6-12 months afterward. Data were collected via a self-reported questionnaire at baseline/first intervention (T0), 21 days after first intervention (T0D21), at the second intervention (T1), and 21 days after second intervention (T1D21). Improvement in knowledge and behaviour was compared using the chi-square test with an alpha level of 5%. The final data sample of 5,148 schoolchildren was evaluated, and the analysis revealed that 25% more of the schoolchildren brushed their teeth twice a day after the first intervention. The programme was more effective among the 7-9 years age group. The BDN intervention increased brushing-frequency in children at the first intervention, and this was sustained after 6-12 months. Therefore, this programme illustrated a sustainable approach to improve children's oral health knowledge and behaviour.

Gender differences in the pathways of family factors influencing children's oral health behaviours: a cross-sectional study of primary school students in Beijing, China

OBJECTIVE

Research on what family factors influence children's oral health behaviours (COHB) in developing countries is limited, and there have been no path analyses accounting for gender differences in these factors. Thus, our study evaluated gender differences in COHB including the influencing pathways of family factors in China.

MATERIALS AND METHODS

Through multistage cluster sampling, 915 pairs of mothers and children from six public elementary schools in Beijing completed self-administered questionnaires regarding COHB, parents' modelling behaviours (PMB), parents' controlling behaviours (PCB), parents' oral health knowledge and attitudes (PKA), and children's oral health knowledge and attitudes (CKA). The influencing factors were analysed using path analysis.

RESULTS

Compared with boys, girls showed significantly better performance in drinking less carbonated drinks regularly (8.6% vs. 16.9%). For both genders, PMB shad a significant direct influence on COHB, while PKA had an indirect influence through PMB. In the boys' model, PKA indirectly influenced COHB through CKA. In the girls' model, socioeconomic status had a positive direct effect on COHB.

CONCLUSIONS

The gender differences were not as large as expected. Given that slightly different influential factors for COHB exist between boys and girls, interventions should take note of the similarities and differences in pathways.

Combining self-management cues with incentives to promote interdental cleaning among Indian periodontal disease outpatients

Background

Periodontal disease is a significant public health issue worldwide. Motivational techniques in combination with financial incentives are shown to lead to effective behavior change. The current study sought to examine whether a brief oral health promotion program (self-management cues that were based on self-efficacy and self-regulatory skills) in combination with an incentive (free dental treatment) would make a difference in the adoption of regular dental flossing in a population of Indian periodontal disease outpatients.

Methods

One hundred and twelve participants (n = 55 oral health promotion intervention group; n = 57 control group) were assigned to the intervention (self-management cues + incentive) or control groups, and follow-up assessments were performed three weeks later. Flossing frequency, behavioral intentions, and perceived self-efficacy served as dependent variables. Data were analyzed with mixed models, ANCOVAs, and path analyses.

Results

The intervention yielded effects on flossing frequency (p < 0.01) and flossing intentions (p < 0.01) at follow-up. Women developed stronger intentions than men. Moreover, by path analysis a sequential mediation chain was found that demonstrated an indirect effect of the intervention on flossing via self-efficacy and intentions: the intervention predicted changes in self-efficacy which, in turn, were associated with changes in intentions, predicting flossing frequency at follow up, while controlling for baseline behavior, gender, and age.

Conclusions

Combining incentives with minimal self-management cues has been found effective in improving interdental cleaning intentions and habits in periodontal disease patients, and the facilitating role of dental self-efficacy has been demonstrated.

Association between family factors and children's oral health behaviors--a cross-sectional comparative study of permanent resident and migrant children in large cities in China

OBJECTIVES

To examine the association of family factors on oral health behaviors of children and compare them between permanent residents and migrant children.

METHODS

A total of 3015 children in grades 4, 5, and 6 from 16 elementary schools and their parents in Beijing and Guangzhou, China, were selected through multistage stratified cluster random sampling. Questionnaires constructed for this study were self-completed by children and parents to collect information on children's oral health behaviors (COHB), parents' modeling behaviors (PMB), parents' direct controlling behaviors (PDCB), parents' indirect controlling behaviors (PICB), parents' oral health knowledge and attitudes (POHKA), and children's oral health knowledge and attitudes (COHKA). Correlation analysis and path analysis were used to explore the correlation between COHB and PMB, as well as the effects of family factors [socioeconomic status (SES), PMB, PDCB, PICB, and POHKA on COHB].

RESULTS

Considering all participants, the rates of behavioral similarities of parents and children were 63.8-86.1%, all showing statistical significance. For family factors included, PMB, SES, PICB, and POHKA demonstrated positive relationships with COHB with standardized coefficients of 0.200, 0.122, 0.040, and 0.059 in residents and 0.160, 0.121, 0.090, and 0.041 in migrants, respectively. Family SES was associated with COHB directly and indirectly to a similar degree. In migrants, the relationship between COHKA and COHB was greater than that between PMB and COHB. COHB scores were higher in younger children. In residents, the relationship between PMB and COHB was greater than that between COHKA and COHB. COHB scores were slightly higher in older children indirectly influenced by increases in COHKA.

CONCLUSIONS

Parents' behaviors shared relatively high similarities with COHB and family factors were associated with COHB greatly. The relationship between PMB and COHB was less than that between COHKA and COHB in migrants. The association between family factors and COHB in disadvantaged populations should be considered when designing children's health education programs.