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Original Article

Association between family structure and oral health

of children with mixed dentition in suburban Nigeria
Morenike Oluwatoyin Folayan1,2,3, Kikelomo Adebanke Kolawole1,2,3, Elizabeth O Oziegbe1,2,3,
Titus A Oyedele2,3, Hakeem O Agbaje2,3, Nneka Kate Onjejaka2,3, Victor Olasegun Oshomoji2,3
1
Department of Child Dental Health, Obafemi Awolowo University, 2Oral Habit Study Group, 3Department of Child Dental Health,
Obafemi Awolowo University Teaching Hospitals Complex, Ile‑Ife, Nigeria

ABSTRACT Address for correspondence:

Dr. Morenike Oluwatoyin Folayan,
Context: Family structures can affect the oral
Department of Child Dental Health, Obafemi Awolowo
health of the child. However, little is known University, Ile‑Ife, Nigeria.
about the impact of the family structure on oral E‑mail: toyinukpong@yahoo.co.uk
health of children in Africa. Aims: To determine
the association between family structure,
twice daily toothbrushing, use of fluoridated Access this article online
toothpaste, caries, and oral hygiene status of Quick response code Website:
5–12‑year‑old children resident in semi‑urban www.jisppd.com
Nigeria. Settings and Design: Secondary DOI:
analysis of the data of 601 children recruited
10.4103/0970-4388.206034
through a household survey conducted in Ile‑Ife,
PMID:
Nigeria. Subjects and Methods: The association
between dependent variables (presence of ******

caries, good oral hygiene, use of fluoridated

toothpaste, and twice daily toothbrushing) and
the family structure (parental structure, number
of siblings, and birth rank) was determined.
Statistical Analysis Used: Simple and multivariate
regression analysis was used to determine the
association. The regression models were adjusted
for age and gender. Results: Children who were
not primogenitor had significantly reduced odds
of using fluoridated toothpaste (AOR: 0.91; 95%
confidence interval  [CI]: 0.85–0.97; P =  0.01) when
compared with children who were primogenitors
or only children. Furthermore, having 0–2 siblings
significantly reduced the odds of having caries
(AOR: 0.46; CI: 0.28–0.78; P < 0.001) when compared
with children who had three or more siblings.
Children who used fluoridated toothpaste had
significantly increased odds of having good oral
hygiene (AOR: 1.64; 95% CI: 1.18–2.28; P <  0.001).
Conclusions: For this study population, the number
of siblings and the birth rank increased the chances
of having caries and use of fluoridated toothpaste,
respectively.
KEYWORDS: Caries, children, family, Nigeria, oral
hygiene, toothpaste
Introduction
A number of social factors predisposing children and
adults to dental caries and poor oral hygiene are being
identified. For example, the occupation, education, and
income of children’s parents can have a significant impact
on the children’s access to oral health care.[1,2] In addition,
the child’s family structure is an important social factor
that has a significant impact on the oral health of children,
playing a critical role on how the physical and emotional
support needed to cope with a disease, its treatment, and
its financial burden are provided.[3]
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work non‑commercially,
as long as the author is credited and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Folayan MO, Kolawole KA,
Oziegbe EO, Oyedele TA, Agbaje HO, Onjejaka NK, et al.
Association between family structure and oral health of children
with mixed dentition in suburban Nigeria. J Indian Soc Pedod
Prev Dent 2017;35:134-42.

134 © 2017 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
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The relationship between family structure and certain
health outcomes, especially those affecting adolescents,
has been reported in several studies[4,5] with a number
of articles reporting statistically significant associations
between family structure and the oral health of
adolescents.[6‑8] For example, in the United  Kingdom,
single mothers and mothers with more than two
children are significantly less likely to use dental services
than are mothers living with spouses and having not
more than two children.[6] Furthermore, children from
single parent families are disproportionately affected
by caries and low level of use of dental services.[9,10]
Ola et al.[8] had shown that even in an African country,
children living with single mothers or without a parent
were unlikely to have visited a dentist just as observed
in developed countries.
While the differences in the caries status for children
from various family structures might have resulted
from the families’ socioeconomic status and its influence
on the child’s dietary habits, there are still subtle
differences in family structure that may have significant
consequences on the oral health of children. Two of
these factors include the birth rank of the child and the
number of siblings the child has.[11‑13] Studies show that
birth rank affects the personality of the individual[14]
while others have not.[15] Individual personalities have
a significant impact on health.[16] An only child tends to
show traits similar to first children[17] and seem to have
higher self‑esteem than children with siblings.[18] They,
just like first children, engaged less in oral health risk
behaviors such as smoking, intake of alcohol, and use
of psychoactive substances.[19] Zadik[20] found less caries
prevalence in first children while Mansbridge[21] did not.
There are also suggestions that the family size increases
the risk for child morbidity and mortality as larger
family sizes reduce the marginal cost of child quality.[22]
Some empirical data, however, suggest that the family
size does not have an impact on health.[23,24] Family size
has also been associated with an increased incidence of
caries and poor oral health[8,25,26] with the risk for caries
increasing with increase in the number of siblings.[27,28]
Unfortunately, very little is known about how the
family structure in Africa influences access to dental
health services, use of caries prevention practices, and
oral hygiene status. Family structures in many African
settings differ from those in Europe and America,
where most studies on the impact of family structure
on health care had been conducted. In Nigeria, a
high number  (9%) of children live without biological
parents.[29] Many children living with guardians do
not receive the much needed attention as do biological
children living with parents.[30] Learning how family
structures in different cultures impact on oral health is,
therefore, important.
This study explored the association between family
structure (number of siblings, birth rank, and
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 2 | April-June 2017 |
Folayan, et al.: Family structure and oral health of children
parental structure), oral hygiene practices (twice daily
toothbrushing and use of fluoridated toothpaste),
caries, and oral hygiene status of children in the mixed
dentition stage  (aged 5–12  years) in a representative
sample of residents in Ife Central Local Government
Area (LGA) of Osun State, Nigeria.
Subjects and Methods
This study is a secondary analysis of data collected
through a household survey to determine the
association between digit sucking and caries. Part
of the study data was published elsewhere[31‑33] and
included details of the household survey, sample
size determination, sampling techniques, and data
collection process.
Study design
Data were collected through a cross‑sectional study
using a household survey because it increased the
probability of including children targeted for the
study from all the socioeconomic strata in the study
population, irrespective of their ability to be enrolled
in school or not. Data collection was done during
evenings of the weekend of the summer holidays (July
to August 2013) when most participants and their
parents will likely be home.
Study setting
The semi‑urban Ife Central LGA of Osun State was
chosen as the study location due to its proximity
to Obafemi Awolowo University and Obafemi
Awolowo University Teaching Hospitals Complex,
the host institutions of the authors. The 1991 census
put the population of the LGA at 96,580. The
estimated population for 2004 is 138,818, including a
child population of 14,000, or about 10% of the total
population.
Study population
For this analysis, only children between the ages of 5
and 12  years were included in the study. The lower
age limit of 5  years was based on the typical age
of the first eruption of permanent dentition in the
study population.[34] Only children who were present
in the home at the time of the study were eligible to
participate in the study.
Sample size determination
Sample size was calculated using the formula by
Araoye.[35] The caries prevalence of 13.9%[36] was
used for determine the sample size required for
this study. The required minimum sample for the
study was approximately 200 having adjusted for
a margin of error of 5% and a confidence level of
95%. The data of 601 children were accessible for
the primary based on this secondary data analysis.
The data retrieved for this study are, therefore,
adequate.
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Folayan, et al.: Family structure and oral health of children
Sampling technique
Detailed information on the sampling technique for
the study had been reported by Kolawole et al.[33] The
sampling procedure used was a three‑level cluster
sampling technique. Stage 1 involved the selection
of enumeration sites for data collection by balloting.
Stage 2 involved the selection of every third household
on each street in randomly selected enumeration sites
within the LGA. Stage 3 involved the selection of actual
respondents for interview and clinical examination.
Only one eligible child in each household was selected
to participate in the study in the household.
Data collection
Data were collected through personal interviews
using of a structured questionnaire administered by
trained field workers. Mothers or surrogate mothers
responded to the questions on oral health practices on
behalf of children aged 5–7  years, based on evidence
that their responses were more accurate than the
children.[37] When the mother was unavailable, the
fathers completed the questionnaires. Children aged
8–12  years old were directly asked about their oral
health practices.
Data retrieved for this study include each child’s
sociodemographic characteristics (age at last birthday
and sex), parental structure  (living with mother and
father, single parents, or with neither parents), number
of siblings, and birth rank. It also retrieved details on
oral hygiene practices such as toothbrushing frequency
and use of fluoridated toothpaste. These questions had
four to seven alternatives. To define acceptable levels
of each of the components, the following cutoff points
were used: Brushing more than once a day and using
fluoridated toothpaste always. Respondents who chose
the options “irregularly or never,” “once a week,” “a
few (2–3) times a week,” or “once a day,” when asked
the question on toothbrushing, were classified as not
having undertaken caries preventive practices. Those
who chose the options, i.e.  “quite often,” “seldom,”
or “not at all” when asked the question on the use of
fluoridated toothpaste were classified as not having
undertaken caries preventive practices.[31]
Intraoral examination
All study participants underwent oral examinations in
their homes on the day of study visits.[33] They were
examined under natural light while sitting, by trained
dentists and accompanying field workers, using sterile
dental mirrors and probes. Radiographs were not taken
in the study. Caries status was determined before the
oral hygiene status. Caries diagnosis was based on
the recommendation of the WHO Oral Health Survey
methods.[38] The caries status was assessed by the use
of the decayed, missing, and filled teeth/decayed,
missing, and filled teeth (dmft/DMFT) index. Children
were classified as having caries present when a tooth
was identified as decayed, missing, or filled.
136 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 2 | April-June 2017 |
The Simplified Oral Hygiene Index (OHI‑S) by Greene
and Vermillion[39] was used to determine the oral
hygiene status. The OHI‑S components, the debris
index and calculus index, were obtained based on six
numerical determinations representing the amount
of debris or calculus found on the facial or lingual
surfaces of index teeth 8, 3, 14, 24, 19, and 30 in the
permanent dentition and A, E, F, K, O, and P in the
primary dentition. The debris and calculus index scores
were added and divided by the number of surfaces
examined to give the OHI‑S score. The oral hygiene
was classified as good, fair, or poor when the score
ranges were 0.0–1.2, 1.3–3.0, and >3.0, respectively.
Standardization of clinical examiners
Four examiners, who were qualified dentists,
undertook a series of calibration exercises to ensure the
validity of their evaluations. The exercises included
protocol‑based training on the WHO criteria for the
diagnosis of caries,[38] and the OHI‑S index described by
Greene and Vermillion.[39] The calibration process and
the calibration outcome were reported by Kolawole
et al.[33]
Data analysis
All the variables in the data were coded, entered
into a computer, analyzed by the use of STATA
(version  12.0),  and checked for missing values and
entry errors. Descriptive analysis was conducted by
the use of measures of location and dispersion. Simple
and multivariate regression with robust variance
estimation was used to derive prevalence ratios with
95% confidence interval (CI).
A hierarchical model was used to manage the variables
as this enabled us assess the influence of each variable
on the outcome as well as allow for control of the
effects if confounder effects on the association. Thus,
a stepwise selection was done in the multivariate
regression with significance level for removal from
model set at 0.2. Factors that could also have a
significant impact on the outcomes were also included
in the multivariate analysis irrespective of the P value
obtained in the simple regression analysis.
For data analysis purposes, age was dichotomized into
5–8 years and 9–12 years. Birth rank was dichotomized
into “not primogenitor” and “primogenitor or only
child” using the criteria set by Ola et al.[8] The number
of siblings was also dichotomized into 0–2 siblings
and >3 siblings as used in the study by Ola et al.[8] For
the logistic regression analysis, parental structure was
also dichotomized to “both parent” and “not both
parents.” All respondents who lived with mother
only, father only, one parent and one step‑parent, and
no parents were grouped into “not both parents.” All
children were categorized as either having caries or
caries free. Oral hygiene status was dichotomized to
good and poor (fair and poor) oral hygiene.
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Folayan, et al.: Family structure and oral health of children

Four different outcomes were considered in the Table 1: Frequency distribution of demographic
analysis and described as follows:  (a) “Having used variables, family structure, oral hygiene practices,
fluoridated toothpastes or not;”  (b) “having brushed caries experience, and oral hygiene experience in a
teeth twice daily or not;”  (c) “having caries or not;” sample of 601 children
and  (d) “having good oral hygiene or not.” The first
Demographic profile N=601 N (%)
two variables were chosen based on the outcome of
Age
the study by Folayan et al.[40] that showed that use of
5years-8 years 363 (60.4)
fluoridated toothpaste and toothbrushing twice daily
9years-12 years 238 (39.4)
were the most significant factors for reducing caries in
children in the study population. Statistical significance Gender
was defined as P < 0.05. Male 291 (48.4)
Female 310 (51.6)
Parental structure
Ethical consideration
Both parents 533 (88.7)
Ethical approval for the study was obtained from
Mother only 39 (6.5)
the Research and Ethics Committee of Obafemi
Father only 5 (0.8)
Awolowo University Teaching Hospitals Complex,
Ile‑Ife. Approval for the conduct of the study was One parent and one step-parent 2 (0.3)
obtained from the Local Government Authority, No parent 7 (1.2)
before the commencement of the study. The primary No response 15 (2.5)
study was conducted in full compliance with the Birth rank
approved protocol and in full accordance with the First born or only child 190 (31.6)
National Health Research Ethics Code which was Not first born 406 (67.6)
developed in accordance with the World Medical No response 5 (0.8)
Association Declaration of Helsinki and other global Number of siblings
bioethics codes. Efforts were made to minimize risks 3 or more 359 (39.7)
to participants such as the loss of confidentiality and 0-2 233 (38.8)
discomfort with the personal nature of questions. No response 9 (1.5)
Written informed consent was obtained from the Oral hygiene practices
parents of all study participants and written assent Brushes teeth twice daily or more 55 (9.2)
obtained from all children aged 8–12  years old who Uses fluoridated toothpaste 506 (84.2)
participated in the primary study. The consenting Consumes sugary snacks in between meals 187 (31.1)
process for the primary study was approved by less than once a day
Obafemi Awolowo University Teaching Hospitals Visited the dental clinic in the last 12 23(3.8)
Complex, Ile‑Ife. Participants in this primary study months
experienced no direct benefit, and no compensation Caries status
was paid. However, participants were given token gifts Caries present (DMFT >0 and dmft >0) 89 (14.8)
of stationery including pencils, erasers, sharpeners, or Caries free(DMFT=0 and dmft =0) 512 (85.2)
a small tube of fluoride‑containing toothpaste that did DMFT
not exceed a value of $0.50. 0 525 (89.4)
1 31 (5.2)
Results 2 25 (4.2)
3 10 (1.7)
Table  1 shows the demographic profile of the study 4 4 (0.7)
participants. The mean age of the study participants 5 4 (0.7)
was 7.9 ±  (2.2) years and 291  (48.4%) were males. 6 1 (0.2)
A large number of study participants lived with both 8 1(0.2)
parents (88.7%). Furthermore, 190 (31.6%) participants DMFT
were primogenitors/only child and 7  (1.2%) 0 478 (95.4)
respondents were not biological children of the family. 1 14(2.8)
2 5(1.0)
Only 23 (3.8%) study participants had visited the dental 3 1(0.2)
clinic in the past 12  months, 55  (9.2%) brushed twice 4 3 (0.6)
daily or more, 187 (31.1%) consumed sugary snacks in Oral hygiene status
between meals less than once a day, and 506  (84.2%) Good 259 (43.2)
used fluoridated toothpaste always. Fair 317 (52.9)
Poor 23 (3.8)
Only 89 (14.8%) study participants had caries. The dmft
ranged from 0 to 8 with a mean dmft of 0.27  ±  (0.85).
One hundred and forty‑two  (90.0%) of the 156 carious and three (1.9%) were filled. The DMFT ranged from 0 to 4
primary teeth were unrestored, 11 (7.1%) were extracted, with a mean DMFT of 0.06 ± (0.38). Twenty‑seven (81.8%)

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Folayan, et al.: Family structure and oral health of children

of the 33 carious permanent teeth were unrestored,
three (9.1%) were extracted, and two (6.1%) were filled.
Table 2 highlights factors associated with toothbrushing
twice daily or more. There was no significant factor
associated with twice daily brushing or more in the
study population. The odds of brushing twice daily
or more reduced for children who were 5–8 years old
when compared with those 9–12  years old (PR: 0.69;
95%CI: 0.42–1.14), and for children who were not
first primogenitors when compared to those who
were primogenitors and only child  (PR: 0.64; 95%
CI: 0.39–1.07). The odds of brushing twice daily or
more increased for males when compared to females
(PR: 1.50; 95%CI: 0.90–2.50).
Table 3 highlights the factors associated with the use of
fluoridated toothpaste. The only significant predictor
was not being a primogenitor: Study participants who
were not primogenitors had reduced odds of using
fluoridated toothpaste when compared to those who
were primogenitors and only child  (APR: 0.91; 95%
CI 0.85–0.97).
Table  4 highlights the factors associated with the
presence of caries. There were two significant factors
associated with the presence of caries. Having 0–2
siblings reduced the odds of having caries when
compared with those with three or more siblings
(APR: 0.47; CI: 0.28–0.79). Furthermore, brushing the
teeth twice daily or more increased the odds of having
caries when compared with those who only brushed
once daily (APR: 1.72; 9% CI: 1.00–2.95).
Table 5 highlights the factors associated with good oral
hygiene. Age and use of fluoridated toothpaste were
the only significant factors associated with good oral
hygiene. Children aged 5–8  years old had increased
odds of having good oral hygiene when compared
with children aged 9–12  years old (APR: 1.57; 95%
CI: 1.27–1.93). Furthermore, children who used
fluoridated toothpaste had increased odds of having
good oral hygiene when compared with those
who did not use fluoridated toothpaste (APR: 1.64;
95% CI: 1.18–2.26). Toothbrushing twice daily or
more had no significant association with good oral
hygiene (P = 0.84).
Discussion
This study presents important information on oral
hygiene practices and family structures associated
with the presence of caries and good oral hygiene. We
identified a family structure‑related variable associated
with the use of caries prevention methods  –  not
being a primogenitor reduced the probability of
using fluoridated toothpaste. We also found a
family structure‑related variable associated with
caries  –  children who had 0–2 siblings had reduced
probability of developing caries. We also found
that toothbrushing twice daily or more increased
the probability of having caries, whereas the use of
fluoridated toothpaste increased the probability of
having good oral hygiene.
The findings of this study are important for addressing
the long‑term oral health care needs of children in the
study population. The mixed dentition stage is a time of
significant hormonal changes, with associated physical
and psychological development of the child.[41] It is a
period during which the child commences transition from
childhood to adolescence,[42] and a time when children

Table 2: Frequency distribution and results of simple and multivariate regression analysis for the association
between demographic variables, family structure, and twice daily tooth brushing in a sample of 601 children
Demographic variables Brush teeth twice daily Simple regression Multivariate regression
Yes (%) N=55 No (%) N=546 PR (95% CI) P PR (95% CI) P
Age  
5-8 years 29 (52.7) 334 (61.2) 0.73 (0.44-1.21) 0.22 0.69 (0.42-1.14) 0.15
9-12 years 26 (41.3) 212 (38.8) 1 1
Gender
Male 32 (58.2) 259 (41.4) 1.48 (0.89-2.47) 0.13 1.50 (0.90-2.50) 0.12
Female 23 (41.8) 287 (52.6) 1 1
Parental structure
Both parents 46 (83.6) 487 (89.2) 1 - -
Mother only 6 (10.9) 48 (8.8) 1.29 (0.58-2.88) 0.54 - -
Father only 1 (1.8) 4 (0.7) 2.32 (0.39-13.69) 0.35 - -
One parent and one step-parent 1 (1.8) 1(0.2) 5.79 (1.41-23.83) 0.02 - -
No parents 1 (1.8) 6 (1.1) 1.66 (0.26-10.39) 0.59 - -
Birth rank
Not first born 27 (49.1) 206 (37.7) 0.66 (0.40-1.09) 0.10 0.64 (0.39-1.07) 0.09
First born or only child 28 (50.9) 340 (62.3) 1 1
Number of siblings
0-2 21 (38.8) 169 (31.0) 1.34 (0.80-2.24) 0.27 - -
3 or more 34 (61.2) 377 (69.0) 1 - -

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Folayan, et al.: Family structure and oral health of children

Table 3: Frequency distribution and results of logistic regression analysis for the association between
demographic variables, family structure, and use of fluoridated toothpaste in a sample of 601 children
Demographic variables Use fluoridated toothpaste always Simple regression Multivariate regression
Yes (%) N=506 No (%) N=95 PR (95% CI) P PR (95% CI) P
Age  
5-8 years 302 (59.7) 61 (64.2) 0.97 (0.91-1.04) 0.40 - -
9-12 years 204 (40.3) 34 (35.8) 1 - -
Gender
Male 244 (48.2) 47 (49.5) 0.99 (0.93-1.06) 0.82 - -
Female 262 (51.8) 48 (51.5) 1 - -
Parental structure
Both parents 445 (87.9) 88 (92.6) 1 1
Mother only 48 (9.5) 6 (6.3) 1.06 (0.96-1.18) 0.23 1.06 (0.96-1.18) 0.23
Father only 4 (0.7) 1 (1.1) 0.96 (0.62-1.49) 0.85 0.92 (0.61-1.39) 0.69
One parent and one step-parent 2 (0.5) 0 (0.0) 1.20 (1.15-1.24) <0.001 1.24 (1.18-1.30) <0.001
No parents 7 (1.4) 0 (0.0) 1.20 (1.15-1.24) <0.001 1.16 (1.10-1.22) 0.01
Birth rank
Not first born 298 (58.9) 70 (73.7) 0.91 (0.85-0.97) 0.01 0.91 (0.85-0.97) 0.01
First born or only child 208 (41.1) 25 (26.3) 1 1
Number of siblings
0-2 165 (32.6) 25 (26.3) 1.05 (0.98-1.12) 0.21 - -
3 or more 341 (67.4) 70 (73.7) 1 - -

Table 4: Frequency distribution and results of logistics regression analysis for the association between
demographic variables, family structure and presence of caries in a sample of 601 children
Demographic variables Caries present Simple regression Multivariate regression
Yes (%) N=89 No (%) N=512 PR (95% CI) P PR (95% CI) P
Age    
5-8 years 51 (57.3) 312 (60.9) 0.88 (0.60-1.30) 0.52 - -
9-12 years 32 (42.7) 200 (39.1) 1 - -
Gender
Male 36 (40.5) 255 (49.8) 0.72 (0.49-1.07) 0.11 0.71 (0.48-1.06) 0.09
Female 53 (59.5) 257 (50.2) 1 1
Parental structure
Both parents 79 (88.8) 454 (88.7) 1 1
Mother only 8 (9.0) 46 (9.0) 1.00 (0.51-1.96) 1.00 1.09 (0.57-2.08) 0.79
Father only 1 (1.1) 4 (0.7) 1.35 (0.23-7.89) 0.74 1.48 (0.21-10.48) 0.69
One parent and one step-parent 0 (0.0) 2 (0.4) 0.00 (0.00-0.00) <0.001 0.00 (0.00-0.00) <0.001
No parents 1 (1.1) 6 (1.2) 0.96 (0.16-5.99) 0.97 0.97 (0.28-0.78) <0.001
Birth rank
Not first born 73 (82.0) 338 (66.0) 1.18 (0.79-1.77) 0.41 - -
First born or only child 16 (18.0) 174 (34.0) 1 - -
Number of siblings
0-2 16 (18.0) 174(34.0) 0.47 (0.28-0.79) <0.001 0.47 (0.28-0.79) <0.001
3 or more 73 (82.0) 338 (66.0) 1 1
Brush twice daily
Yes 12 (13.5) 43 (8.4) 1.55 (0.90-2.66) 0.11 1.72 (1.00-2.95) 0.05
No 77 (86.5) 469 (91.6) 1 1
Use fluoridated toothpaste always
Yes 74 (83.1) 432 (84.4) 0.93 (0.56-1.54) 0.77 - -
No 15 (16.9) 80 (15.6) 1 - -

are establishing their independence from parental
influence.[43] Their independence has implications for oral
health‑care practices one of which is the possibility of less
supervision of home oral health‑care practices such as
brushing and flossing teeth, thereby increasing the risk
for poor oral hygiene practices.[44] It is also a time when
the consumption of sweets, sugary foods, and drinks,
predisposing factors to caries, increases.[44] Identifying
those family structure‑related variables that help promote
oral hygiene practices that reduce caries risk in the mix
dentition stage will guide the design and implement of
public oral health programs and campaigns.

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Folayan, et al.: Family structure and oral health of children

Table 5: Frequency distribution and results of logistic regression analysis for the association between
demographic variables, family structure, and good oral hygiene in a sample of 601 children
Demographic variables Good oral hygiene Simple regression Multivariate regression
Yes (%) N=259 No (%) N=3422 PR (95% CI) P PR (95% CI) P
Age
5-8 years 182 (70.3) 181 (52.9) 1.55 (1.26-1.91) <0.001 1.57 (1.27-1.93) <0.001
9-12 years 77 (29.7) 161 (47.1) 1 1
Gender
Male 121 (46.7) 170 (49.7) 0.93 (0.78-1.12) 0.47 - -
Female 138 (53.3) 172 (50.3) 1 - -
Parental structure
Both parents 231 (89.2) 302 (88.3) 1 - -
Mother only 21 (8.1) 33 (9.6) 0.90 (0.63-1.27) 0.54 - -
Father only 1 (0.4) 4 (1.2) 0.46 (0.08-2.67) 0.39 - -
One parent and one step-parent 1 (0.4) 1 (0.3) 1.15 (0.29-4.63) 0.84 - -
No parents 5 (1.9) 2 (0.6) 1.65 (1.02-2.66) 0.04 - -
Birth rank
Not first born 154 (59.5) 214 (62.6) 0.93 (0.77-1.12) 0.44 - -
First born or only child 105 (40.5) 128 (37.4) 1 - -
Number of siblings
0-2 87 (33.6) 103 (30.1) 1.09 (0.90-1.33) 0.36 - -
3 or more 172 (66.4) 239 (69.9) 1 - -
Brush twice daily
Yes 23 (8.9) 32 (9.4) 0.97 (0.70-1.34) 0.84 - -
No 236 (91.1) 310 (90.6) 1 - -
Use fluoridated toothpaste always
Yes 232 (89.6) 274 (80.1) 1.61 (1.16-2.25) 0.01 1.64 (1.18-2.26) <0.001
No 27 (10.4) 68 (19.9) 1 1

Our study finding indicates that a child’s birth rank
and the number of siblings (s)he has is associated with
the less use of fluoridated toothpaste and the increased
risk for caries, respectively. These two variables are
possibly linked to the family size. Large families may
need to cut down on expenses, including having to
buy cheaper toothpaste, leading to an increased risk
of developing caries. Past studies had highlighted
that the financial and social pressures that come with
having large families often has a negative impact on
the oral health of children[45] including increased risk
for caries.[46]
We also found that toothbrushing twice daily or more
increased the probability of having caries while the use
of fluoridated toothpaste increased the probability of
having good oral hygiene. This finding is paradoxical,
and we cannot find a ready explanation this. One
possibility is that children who brush twice daily
may have been the ones who had had contact with
oral health personnel in the past due to the need to
manage caries. The habit of toothbrushing twice daily
or more may have therefore being instituted to prevent
new caries lesion. The associated good oral hygiene
associated with the use of fluoridated toothpaste in
the absence of an association with toothbrushing is
difficult to explain. We plan to explore this finding
further.
The study was unable to show an association between
parental structure, oral hygiene practices, caries, and
oral hygiene status. This is contrary to the findings of a
number of reports in the field which had demonstrated
this relationship.[46,47] The small number of children
not living with both parents and the small number
of children with caries made it difficult to conduct
meaningful subanalysis to determine specific forms
of parenting structures that may have an impact on
caries risk and affect oral hygiene practices. There is
little known about the effect of parenting structure
on the oral health of children in the study population,
especially where we have a significant number of
children living with guardians. Onyejaka[48] had shown
that in Nigeria, children who live with guardians are left
behind with respect to dental service utilization despite
interventions. It will be important to conduct a study
primarily focus on answering this research question.
This study has limitations. The outcome of analysis of
the household survey makes the study finding only
generalizable to the study population and cannot be
extrapolated to represent Nigeria. It cannot also reflect
what happens in other suburban communities in
Nigeria considering how diverse and heterogeneous
Nigeria is.[49] Furthermore, with a cross‑sectional study,
it is difficult to ascertain the direction of the established
relationships between the variables.

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Conclusions
The study highlights that birth rank and number of
siblings are significantly associated with caries risk
reduction practices and caries risk, respectively. These
findings further add to public understanding about
how the social context of the lives of children informs
their oral health. While it would be an uphill task to try
and moderate these factors in an effort to reduce caries
risk of children and adolescents with mixed dentition
using a public health approach, these factors should
help clinicians help identify children at higher risk for
caries and thereby manage them appropriately.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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