Assessment of Oral Health Literacy of Parents Regarding Their Children’s Oral Health: A Cross-Sectional Study

Introduction

Oral health literacy (OHL), defined as individuals’ understanding of fundamental concepts regarding their oral health, is critical in predicting oral health outcomes; this is especially the case among children, whose dental care decisions and actions are dependent on their parents [1]. OHL includes the ability of an individual to obtain, understand, and use basic health knowledge in the process of making relevant decisions in areas of health [2]. In the area of children’s dental health, change lies in parental knowledge and behavior because the parents are responsible for creating an oral hygiene schedule, choosing dental appointments, and providing babies with preventive dental care [3]. Because children’s oral health reflects the knowledge and practices of their parents or caregivers, it is important to analyze parental OHL to address the larger issue of oral health inequalities and to improve the prognosis of young people.

Children’s oral health is a public health concern; dental caries is among the world’s most prevalent non-communicable diseases among children [4]. Despite having modifiable causes, dental caries continues to be a major health problem across industrialized and developing countries, since untreated decay can cause discomfort, infection, and other systemic health complications [5]. The early progression of carious lesions is associated with poor hygiene, infrequent visits to a dentist, and inadequate preventive measures, which depend on parents’ knowledge and practices [6]. Therefore, assessment of parents’ OHL is useful to understand how they view and approach their child’s oral health needs and to identify any gaps in their knowledge that may be filled by the promotion of future oral health interventions.

OHL has been proven to have a positive association with children’s oral hygiene practice and oral health behavior, whereby higher parental OHL translates to better children’s oral hygiene and fewer dental problems [7,8].

Although a substantial body of research has examined OHL, little is known about how specific OHL indicators are associated with children’s oral health outcomes across different community groups. Parents play a pivotal role in shaping their children’s oral health behaviors, such as the timing of the first dental visit, supervision of brushing, dietary practices, and utilization of preventive dental care. Understanding parental OHL can therefore provide insights into children’s dental caries risk and overall oral health status. The primary aim of this study is to assess the level of parents’ OHL and examine its relationship with their children’s dental caries, measured using the Decayed, Missing, and Filled Teeth (DMFT) index. Additionally, the study explores how demographic factors, including place of residence, education level, and employment status, influence parental OHL and oral health practices. Parental OHL was measured using the Health Literacy in Dentistry Scale (HeLD-14), a validated 14-item questionnaire assessing communication, understanding, utilization, access, support, and receptivity. Higher scores reflect better literacy and are expected to correlate with lower DMFT scores in children [9].

The current literature suggests that childhood caries affect nearly 50% of children under 12 years of age worldwide and remain a major public health concern. A bibliometric review by Zhai et al analyzed 2178 publications from 2003 to 2023, using CiteSpace to identify global research trends and collaborations. The results indicate a 3-fold increase in research output over the past 2 decades, led primarily by the United States and Brazil. International collaboration has expanded significantly, involving 108 countries worldwide. Key challenges include persistent socioeconomic disparities, limited access to treatments, such as silver diamine fluoride, and the complex influence of the oral microbiome on the disease. Despite growing research efforts, the burden of this disease remains disproportionately high in low- and middle-income countries. The study highlights the need to translate research into practice and develop targeted interventions and policies to reduce global inequalities in childhood caries [10]. Therefore, in the present study, we aimed to evaluate OHL among 692 parents of children aged 2 to 12 years using the HeLD-14 and child oral health using the DMFT index.

Material and Methods

ETHICAL CONSIDERATIONS:

This study was approved by the Institutional Ethics Committee (EC-217/PERIO/ND35/2024(a)). The participants volunteered for the present study, and written informed consent was obtained after we explained the study protocol, significance, and methodology. Specific precautions were taken to ensure participant identity remained undisclosed; all information also had to be anonymized in the analysis phase.

STUDY DESIGN:

The primary purpose of this cross-sectional study was to assess the degree to which parents’ OHL affected their children’s dental health. Data were collected during a 6-month period from 692 participants at selected pediatric dental clinics and community health facilities.

STUDY POPULATION:

The inclusion criteria for participation in this study were (1) parents or primary caregivers of children up to 12 years of age, (2) understanding of the study language(s), and (3) willingness to give written informed consent. Parents whose children had significant systemic disease of the body or tissues affecting the oral tissues were excluded, as were parents with physical or mental disabilities that would prevent compliance in the study.

SAMPLING METHOD:

This study used the stratified random sampling technique in choosing participants for the study, to give equal representation of individuals of different socioeconomic classes. Participants were recruited from outpatient departments of pediatric dental clinics and from community-based oral health education and outreach programs. The study population was selected using a stratified sampling method to ensure adequate representation of key subgroups. Stratification was performed based on criteria including the age group of children, type of school (government or private), geographic area (urban or rural), and socioeconomic status, as these criteria are known to influence children’s oral health outcomes and parental OHL, thereby minimizing selection bias and improving representativeness.

DATA COLLECTION:

Data were gathered through a 2-step process, as follows.

QUESTIONNAIRE-BASED SURVEY:

A structured, validated questionnaire was used to assess parental OHL, with responses recorded using multiple-choice and Likert-scale options. The questionnaire included sections on parent and child data, general information, and knowledge and practices. Parent and child data were collected via Google Forms, allowing participants ample time to complete the questionnaire. Incomplete responses were excluded from analysis. Confidentiality was ensured through anonymization and secure data storage. The study protocol and methodology were explained to participants before obtaining consent. General information, including socio-demographic characteristics such as age, sex, education level, employment status, and place of residence (rural or urban) was collected (Table 1). Data on knowledge and practices included 15 questions focusing on parents’ understanding and behaviors regarding their child’s oral health, including the timing of the first dental visit and initiation of oral cleaning; factors contributing to dental caries and malaligned teeth; supervision of tooth brushing, choice of toothpaste, brushing techniques, and frequency of toothbrush replacement; dietary habits affecting oral health; and attitudes toward professional dental care for primary teeth, use of mouthguards, and fluoridated toothpaste (Table 2).

CLINICAL ORAL HEALTH ASSESSMENT:

Oral health assessments were conducted by a single calibrated dental examiner trained in pediatric oral examination techniques. Caries in permanent and primary teeth were evaluated using the DMFT index, while overall oral hygiene was assessed with the Oral Health Index-Simplified, which are both internationally validated measures. Examinations were standardized, following strict infection control protocols, using sterile instruments, dental mirrors, and applicators under adequate lighting. Findings were systematically recorded on structured datasheets, detailing carious, missing, and filled teeth as well as oral hygiene status, ensuring consistent, reliable, and comprehensive evaluation of each child’s oral health. The DMFT index is recommended by the World Health Organization for oral health surveys and is useful for evaluating disease burden, treatment needs, and overall oral health status in populations.

DATA ENTRY AND QUALITY CONTROL:

To maintain quality of measurements in terms of interobserver variation, training and calibration sessions were conducted for all the researchers and clinical examiners. To ensure validity and reliability, the survey instrument was administered to a pilot sample of 20 individuals, and changes were made depending on their feedback. To minimize errors during data analysis and to ensure data accuracy and reliability in the collected data, double data entry was performed. Two independent individuals entered the collected data separately into identical data entry templates. The 2 datasets were then compared using data validation tools. In cases in which discrepancies were identified between the 2 datasets, the original data collection forms were reviewed. The discrepancy was resolved by referring back to the source document, and corrections were made accordingly. This verification process minimized transcription errors and enhanced data integrity.

STATISTICAL ANALYSIS:

In the present study, statistical analyses were done using the Statistical Package for the Social Sciences (SPSS version 26.0, IBM Corp, Armonk, NY, USA). Participants’ demographic data, OHL scores, and clinical variables were presented using frequency distributions, percentages, means, and standard deviations. The association between OHL and clinical oral health indices was analyzed using chi-square tests and Pearson correlation coefficients. Binary logistic regression analysis was used to identify potential predictors of child oral health practices and condition based on OHL. The level of significance was established at P<0.05.

Results

PARENTAL KNOWLEDGE AND PRACTICES:

Knowledge of factors contributing to malaligned teeth was moderate, with 56.2% of parents correctly identifying genetic factors, thumb sucking, and mouth breathing as causes (P=0.002). Overall compliance with daily oral hygiene was good, as 78.3% of parents assisted their children with tooth brushing. Knowledge of dental caries etiology was moderately high, with 63.4% recognizing bacteria, excessive sugar, and sticky foods as causative factors (P=0.005). Preventive practices, however, were less consistent: 36.1% of parents reported taking their child to the dentist, when necessary, while only 28.9% adhered to the recommended twice-yearly visits. Toothbrush replacement practices were suboptimal, with 45.1% replacing brushes when bristles were worn and 32.5% replacing them every 6 months, which may not adequately prevent plaque accumulation. Correct responses to questions about the first dental visit and initiation of oral hygiene were limited, with only 21.7% and 35.1% of parents answering correctly, respectively, highlighting gaps in knowledge regarding recommended early childhood oral care (Tables 2–4).

ORAL HEALTH STATUS OF CHILDREN (DMFT) AND ITS ASSOCIATION WITH PARENTERAL OHL:

The children’s dental health, assessed using the DMFT index, is summarized in Table 5. Half of the children had DMFT scores of 1 or lower, indicating adequate preventive care, while the overall mean DMFT score was 2.8±1.2, reflecting a moderate level of decay. Significant differences were observed based on residence: children living in urban areas had lower mean DMFT scores (2.5±1.1) than did children living in rural areas (3.2±1.3, P=0.002), suggesting better access to dental services and preventive care in urban areas. Two key hypotheses were tested: parental OHL and children’s oral health outcomes are influenced by demographic predictors, and factors such as age, education, and employment significantly predict parental literacy and practices. Education level was the strongest predictor (P<0.001), followed by urban residence (P=0.005) and employment status (P=0.032). These findings indicate that higher parental education level, urban living, and active employment status enhance OHL, which in turn improves children’s oral health (Table 6).

The evaluation of DMFT averages of children in urban and rural areas through the box plot shows a significant difference in oral health of children by area. The result further showed that the median DMFT score was lower among children in urban areas than in children in rural areas, suggesting improved oral health status among children in urban areas. Also, more variation was displayed in low DMFT scores among children in urban areas, which might indicate that oral health practices and access to dental care were relatively better in the urban areas. These findings highlight both external influences, for example, factors linked to the availability and familiarity with dental services, which are often more prevalent in urban settings (Figure 1).

As shown in the scatter plot (Figure 2), there was an inverse relationship between parental OHL, measured by the HeLD-14, and children’s dental caries, expressed as DMFT scores. Higher parental HeLD-14 scores were associated with lower DMFT scores in children, indicating that greater parental understanding of oral health corresponds to better child oral health. The color gradient overlay highlights the distribution of HeLD-14 scores and emphasizes that lower DMFT values are concentrated among children of parents with higher literacy scores. This relationship was statistically significant (r=−0.41, P<0.001), suggesting that improving parental OHL could contribute to a reduction in childhood dental caries.

Discussion

CLINICAL SIGNIFICANCE:

This study highlights the critical role of parental OHL in influencing children’s oral health outcomes. Since parents are the primary decision-makers regarding children’s diet, oral hygiene practices, and utilization of dental services, inadequate parental OHL can contribute to delayed dental visits, poor preventive practices, and a higher prevalence of dental caries. By identifying the association between parental OHL and children’s oral health status, this study provides evidence supporting the incorporation of OHL assessment into routine pediatric dental practice. Clinicians can use this information to design tailored communication strategies, reinforce preventive counseling, and implement early interventions targeted at families with limited OHL.

PUBLIC HEALTH SIGNIFICANCE:

From a public health perspective, dental caries in children remains highly prevalent globally, particularly in low- and middle-income settings where disparities in access to care persist. The findings of this study underscore parental OHL as a modifiable social determinant of health. Strengthening parental knowledge and decision-making capacity through community-based education programs, school health initiatives, and primary healthcare integration can significantly reduce disease burden.

Furthermore, improving OHL aligns with preventive health policies aimed at reducing healthcare costs, minimizing treatment needs, and improving children’s overall quality of life. This study supports the development of targeted public health strategies that address socioeconomic inequities and promote early preventive behaviors.

Conclusions

The present study highlights parental OHL as a key determinant of children’s oral health outcomes. Significant variations in parental OHL across sex, residential location, and employment status contribute to disparities in dental health, with lower OHL associated with higher DMFT scores. The findings emphasize the need for targeted, evidence-based educational interventions, particularly among rural and low-literacy populations. Promoting awareness of early dental visits, timely initiation of oral hygiene practices, and consistent preventive behaviors, such as supervised brushing and appropriate toothbrush replacement, can substantially reduce the burden of dental caries and improve overall oral health in children.