1036663

research-article2021
JDRXXX10.1177/00220345211036663Journal of Dental ResearchEffectiveness of Family-Centered Oral Health Promotion

Research Reports: Clinical

Journal of Dental Research
1­–9
Effectiveness of Family-Centered Oral © International Association for Dental
Research and American Association for Dental,

Health Promotion on Toddler Oral Oral, and Craniofacial Research 2021

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https://doi.org/10.1177/00220345211036663
DOI: 10.1177/00220345211036663
journals.sagepub.com/home/jdr

K.F. Yu1, W. Wen1,2, P. Liu1 , X. Gao1,3,4 , E.C.M. Lo1 ,

and M.C.M. Wong1

Abstract
Early childhood caries is common in Hong Kong, and parental practices on maintaining good oral health of their young children are far
from satisfactory. This article reports on the effectiveness of a randomized controlled trial on family-centered oral health promotion
to new parents in establishing proper feeding habits and oral hygiene practices and in reducing caries risk among 3-y-old toddlers.
At baseline, pregnant mothers and their husbands were recruited and randomly allocated into 2 groups. The test group received
individualized oral health education (OHE) via a behavioral and educational counseling approach while the control group received the
OHE pamphlets only. Information related to the feeding habits, oral hygiene practices, and oral health of the toddlers was collected
by parent-completed questionnaires and oral examination annually via home visits. A total of 580 families were recruited at baseline,
and 436 toddlers were followed up when they reached 3 y old (test, n = 228; control, n = 208; follow-up rate, 75.2%). The proportions
of toddlers who held food in the mouth, fell asleep when milk feeding, had prolonged use of the nursing bottle, ate before bed, and
consumed a sweet snack daily were significantly lower in the test group than in the control group (all P < 0.05). Significantly higher
proportions of toddlers brushed their own teeth twice daily, were brushed by their parents twice daily, and used fluoride toothpaste
than in the control group (all P < 0.001). Toddlers in the test group had better oral health status with a lower level of visible plaque,
Streptococcus mutans, white spot lesion, and cavitated lesion (all P < 0.05). Family-centered oral health promotion and individualized OHE
for parents via a behavioral and educational counseling approach are more effective in establishing good feeding habits and parental
toothbrushing practices and in decreasing the caries risk of their toddlers than the distribution of OHE pamphlets alone (ClinicalTrials.
gov NCT02937194).

Keywords: dental caries, oral hygiene, toothbrushing, preventive dentistry, clinical trial, randomized controlled trial

Introduction
Early childhood caries (ECC) is one of the most prevalent
health problems in preschool children (World Health
Organization 2013) and may have a profound effect on their
physical health and psychosocial status (Leong et al. 2012).
The consequences of untreated ECC can lead to pain, periapi-
cal infection, sleep loss, and childhood distress and may influ-
ence the developing permanent teeth, oral health–related
quality of life, and general health (Martins-Júnior et al. 2013).
In Hong Kong, ECC prevalence has remained unchanged in
the recent 2 decades: 7.6% in toddlers at age 20 mo and 30% to
36% in 3- to 4-y-old children, increasing to 51% in 5-y-old
children with >90% of caries lesions remaining untreated
(Chan et al. 2002; Lo et al. 2009; Wong et al. 2012; Hong Kong
Health Department 2013).
In guidance from the American Academy of Pediatric
Dentistry (AAPD; 2018a) for parents to prevent ECC, mothers
are encouraged to maintain good oral hygiene to reduce the prob-
ability of vertical transmission of cariogenic bacteria (e.g.,
Streptococcus mutans [MS]) from mother to infant. Parents are
recommended to brush their infants’ teeth twice daily as soon as
the first tooth has erupted, using a “smear” of fluoride toothpaste
for toddlers <3 y old. Toddlers are to be weaned off feeding habits
that may increase the caries risk (AAPD 2016, 2018a; World
Health Organization 2016). Regular dental check-ups for infants
should be established no later than age 1 y, as this will help to
detect the initial sign of caries (AAPD 2018b). Better compliance
with these oral hygiene and feeding practices and regular dental
visits from infants to toddlers would ensure better oral health and
quality of life in childhood (Martins-Júnior et al. 2013).
1
Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR,
China
2
Department of Stomatology, Beijing Friendship Hospital, Capital
Medical University, Xicheng District, Beijing, China
3
Faculty of Dentistry, National University of Singapore, Singapore,
Singapore
4
Saw Swee Hock School of Public Health, National University of
Singapore, Singapore, Singapore
A supplemental appendix to this article is available online.
Corresponding Author:
M.C.M. Wong, Faculty of Dentistry, The University of Hong Kong,
34 Hospital Road, Sai Yin Pun, Hong Kong SAR, China.
Email: mcmwong@hku.hk
2 Journal of Dental Research 00(0)
The recommended parental practices are not commonly
performed by parents in Hong Kong, with low percentages of
parents brushing their children’s teeth at a young age and with
high percentages having undesirable feeding habits (Chan
et al. 2002; Chu et al. 2012; Hong Kong Health Department
2013; Jiang et al. 2014; Chen et al. 2017). There is a need to
provide oral health promotion interventions to pregnant women
and new parents to help them establish a routine of brushing
their toddlers’ teeth twice a day and adopt proper dietary and
feeding habits, thereby preventing ECC.
A randomized controlled trial of family-centered oral health
promotions for new parents and their infants was conducted in
Hong Kong to address this challenge. The trial aimed to
increase the proportion of parents brushing their 1-y-old
infants’ teeth, establish proper feeding and dietary habits,
reduce MS colonization, and decrease ECC risk in 3-y-old
toddlers.
This article reports the feeding habits, parental oral hygiene
practices, and oral health status (oral hygiene, MS, and ECC)
of the toddlers at the 3-y-old follow-up in this trial.
Methods
Participant Recruitment
Pregnant women and their husbands were recruited from 2
selected maternal and child health centers and the obstetrics
and gynecology departments of 3 public hospitals in Hong
Kong. The inclusion criteria were 1) first-time pregnancy at 12
to 20 wk of gestation, 2) Chinese ethnicity, 3) good general
health, and 4) ability to communicate in Cantonese or
Mandarin. Written informed consent was obtained from the
pregnant woman and her husband. The recruitment lasted from
June 2014 to June 2016. Ethical approval for this trial was
obtained from the Institutional Review Boards of the University
of Hong Kong (UW 13-163), the Hospital Authority (HKEC-
2014-087, KC/KE-14-0093/FR-2, KW/EX-14-177[79-15]),
and the government Department of Health (L/M 304/2014).
Sample Size Calculation
Sample size calculation was based on the prevalence of ECC in
3-y-olds. By assuming that the prevalence of ECC was 31% in
the control group (Lo et al. 2009) and that a relative 40%
reduction in the test group would be of clinical significance
(i.e., to 19%), a sample size of 204 families in each group was
required to achieve 80% power for a 2-sided test at the 5%
statistical significance level. Then, by assuming a dropout rate
of 30%, 292 families in each group (a total of 584 families)
were needed at baseline.
Randomization and Allocation Concealment
The participants were randomly assigned to 1 of 2 parallel
groups (1:1 allocation ratio) after baseline data collection. The
random number sequence was generated in Excel by an
independent statistician before recruitment. Randomization
with a block size of 4 was adopted, and opaque sealed enve-
lopes were used to conceal the allocation. The envelopes were
opened at the time of group allocation.
Blinding
Due to the nature of the intervention, oral health education
(OHE) providers and participants could not be masked during
this trial. However, dental examiners who collected the clinical
data were blinded to the participants’ group allocation.
Intervention
Test Group: Family-Centered OHE.  The intervention provided
to the pregnant women and their husbands in the test group
was family-centered behavioral and educational counseling
(Liu et al. 2020; Yu 2020; Figure). In brief, oral health pam-
phlets, individual verbal oral hygiene instruction with demon-
stration, and counseling were given by trained dental
professionals to the expectant mothers and their husbands at
baseline. A booklet on infant oral health care (Oral Health
Education Division n.d.) and a demonstration on mouth clean-
ing and toothbrushing were delivered at 32 gestational weeks.
When the infants reached 6 mo old, a reminder regarding
proper feeding and dietary habits and parental toothbrushing
for babies was sent by phone call or text message (after 3
unanswered phone calls). When the toddlers reached 1 and 2 y
old, reinforcement of proper dietary and feeding habits and
parental toothbrushing skills was delivered to parents via
home visits.
Control Group: OHE Pamphlet Distribution.  The control group
participants received the same OHE pamphlets and booklet for
infant oral health care given to the test group at baseline and 32
gestational weeks (Figure).
Data Collection and Outcome Measures
Comprehensive data were collected by a questionnaire, dental
examination, and dental plaque sample collection at baseline,
32 gestational weeks, and annual follow-up after birth.
The oral hygiene and oral health status of the toddlers were
assessed by clinical examination with disposable mouth mir-
rors and an intraoral LED light, as recommended by the World
Health Organization (2013). Food debris was removed to avoid
any incorrect assessment of visible plaque (VP) and dental car-
ies. Oral hygiene status was assessed by the presence of VP on
any tooth. Dental caries was assessed per the ICDAS system
(International Caries Detection and Assessment System; Ismail
et al. 2007). However, ICDAS code 1 could not be used in this
study because no prolonged air drying could be provided in the
dental examination performed in an outreach setting. Presence
of a white spot lesion was recorded by ICDAS code 2, indicat-
ing a distinct visual change in enamel. Presence of a cavitated
lesion (CL) was recorded by ICDAS codes 3 to 6.
Effectiveness of Family-Centered Oral Health Promotion 3

First-time pregnant women & their husbands

Test group Control group

Family-centered OHE (Part I) Standard OHE

Baseline (1) Face-to-face explanation of two OHE pamphlets Distribution of the same adult
(a) “Cleaning your teeth by toothbrushing” and expectant mother oral
- Causes, onset and progression of dental caries and periodontal disease health pamphlets only
- Recommendation on brushing teeth twice daily by using fluoridated
toothpaste and daily flossing
(b) “Oral health for the expectant mother”
- Changes in oral health during pregnancy
- Potential risks of oral health diseases and adverse birth outcome
- Appropriate time for a dental visit during pregnancy
- Benefits of proper tooth-brushing and flossing
(2) Demonstration of toothbrushing (Bass method) and dental flossing using
teeth model
(3) Proposing possible ways to overcome barriers related to toothbrushing and
flossing during pregnancy
(4) Providing individualized advice on the dental health status and answering
the questions raised by new parents

Family-centered OHE (Part II) Standard OHE

32 weeks of (1) Evaluation of new parents’ oral hygiene practices and reinforcement Distribution of the same infant
gestation (2) Explanation of a booklet on infant oral health care oral health care booklet only
- Mouth wiping before tooth eruption and toothbrushing after tooth eruption
- Proper feeding and dietary habits
- Control of sugar consumption
- Avoidance of bacteria transmission
(3) Demonstration of proper technique for wiping or toothbrushing on babies’
anterior teeth using teeth model
(4) Suggestion regarding difficulties the parents may encounter and the possible
solution
(5) Repeat (4) in Part I

6-month follow- Family-centered OHE (Part III)

A reminder sent by a phone call or text message (after 3 unanswered phone calls)
up after infant regarding proper feeding and dietary habits and parental toothbrushing for their
delivery babies

1-year follow-up Family-centered OHE (Part IV)

(1) Reinforcement on toothbrushing for the toddlers’ anterior teeth
after infant (2) Toddlers were encouraged to start toothbrushing by themselves using “tell-
delivery show-do” technique and positive reinforcements such as small toys rewards
were recommended to the parents in successful adoption of toothbrushing
practices in their toddlers
(3) Evaluation of toddlers’ feeding and dietary habits, and suggestion on
reducing sweet snack and beverages intake, particularly before bedtime,
helping parents to modify a more favorable daily diet plan for their toddlers
(4) Reminding parents to arrange regular dental check-ups for their toddlers
starting age 1
(5) Repeat (4) in Part I

2-year follow-up Family-centered OHE (Part V)

(1) Demonstration on brushing the posterior primary teeth on teeth model.
after infant (2) Emphasis on the importance of regular dental check-ups for their toddlers
delivery (3) Reinforcement for the contents covered in Part IV

Figure.  Flowchart of intervention delivered at baseline and follow-ups. OHE, oral health education.

During home visits, the toddlers were examined in a knee- group allocation. Calibration of the examiners with an experi-
to-knee position. Oral examination was carried out by 1 of the enced dental epidemiologist (E.C.M.L.) was arranged prior to
2 trained dentists (W.W. and K.F.Y.) who were blinded to the and regularly during the study. Inter- and intraexaminer
4 Journal of Dental Research 00(0)

Table 1.  Sociodemographic Background of Participating Families at Baseline.

Test Group (n = 294) Control Group (n = 286) Total (n = 580) P Value

Age, y  
 Father 33.9 ± 5.1 33.4 ± 5.2 33.6 ± 5.1 0.238a
 Mother 31.7 ± 3.7 31.6 ± 4.2 31.7 ± 4.0 0.585a
Gestational weeks 14.4 ± 2.6 14.5 ± 2.5 14.4 ± 2.5 0.606a
Father’s education level  
  Junior high school or below 13.9 11.2 12.6 0.298b
  Senior high school 27.9 24.5 26.2  
  Tertiary education or above 58.2 64.3 61.2  
Mother’s education level  
  Junior high school or below 10.9 8.7 9.8 0.129b
  Senior high school 19.7 26.6 23.1  
  Tertiary education or above 69.4 64.7 67.1  
Mother had dental plan cover  
 Yes 39.8 37.8 38.8 0.615b
 No 60.2 62.2 61.2  
Father had dental plan cover  
 Yes 40.5 38.8 39.7 0.682b
 No 59.5 61.2 60.3  
Household income, HKD  
  <20,000 14.9 18.5 16.7 0.161b
  20,000 to <30,000 19.4 21.7 20.5  
  30,000 to <40,000 21.8 16.1 19.0  
  40,000 to <60,000 29.3 24.8 27.1  
  ≥60,000 14.6 18.9 16.7  

Values are presented as mean ± SD or percentage.

a
Two-sample t test.
b
Chi-square test.

reliability of the 2 examiners was monitored by performing
duplicate examinations (8%). Examiner reliabilities were
good: interexaminer (kappa, 0.97 for caries status; kappa, 0.95
for oral hygiene status) and intraexaminer (kappa, 0.98 and
0.97 for caries status; kappa, 0.90 and 0.92 for oral hygiene
status; Lantz and Nebenzahl 1996).
Information on sociodemographic background was col-
lected through questionnaires completed by the parents at
baseline (Table 1), and information on the birth and growth of
the toddlers was collected at the 1-y-old toddler follow-up
(Appendix Table 1). The dietary and feeding habits and oral
hygiene practices of the toddlers (Table 2) were collected at the
annual follow-ups.
Supragingival dental plaque samples of the toddlers were
collected from the buccal surfaces of all teeth with a sterile cot-
ton wrap at the annual follow-ups. Real-time polymerase chain
reaction (PCR) was used to quantify the MS DNA. After cen-
trifugation, the bacteria DNA in the plaque sample was
extracted following the modified protocol of the Gentra
Puregene Extraction Kit (No. 158567 [Qiagen]; Gentra
Systems 2014). Real-time PCR assays were undertaken with a
StepOne Real-Time PCR System, and the reaction reagents
were employed in a preformatted kit (Life Technology) by
using gtfB gene from MS (forward: 5′-CGCACCA
CACGGACTTCA-3′; reverse: 5′-TGGTCAAGAGTAAAGGT
CGGTAAG-3′) and 16S rRNA (forward: 5′-ACTCCTA
CGGGAGGCAGCAGT-3; reverse: 5′-TATTACCGCGGCTG
CTGGC-3), which served as the universal primers. The ratio of
MS in the microbial community in each sample was deter-
mined as the proportion of MS to the total bacterial count.
Statistical Analysis
Descriptive statistics on sociodemographic background and
toddlers’ birth information, feeding habits, oral hygiene prac-
tices, and oral health status were reported and compared
between the test and control groups. Chi-square test and
2-sample t test were used as appropriate in the comparisons.
Negative binomial regression was performed to investigate
the relationships between the number of teeth with CL in
3-y-olds and selected study factors. Independent factors as
covariates with a P value <0.40 in the bivariate analyses were
selected for the model (Appendix Table 2). A life course
approach in the model building was adopted. Select sociode-
mographic background at baseline, feeding habits, and oral
hygiene practices at 1 y old entered the model first. Backward
stepwise selection was employed to remove insignificant vari-
ables from the model. Then selected feeding habits and oral
hygiene practices at 2 y old entered the model, and backward
stepwise selection was employed to remove insignificant vari-
ables. After that, selected feeding habits and oral hygiene prac-
tices at 3 y old entered the model, and backward stepwise
selection was employed again until a final model with only
significant variables was obtained.
Effectiveness of Family-Centered Oral Health Promotion 5

Table 2.  Dietary and Feeding Habits and Oral Hygiene Practices among Toddlers Aged 3 y.

Test Group (n = 228) Control Group (n = 208) Total (n = 436) P Valuea

No. of meals daily

  <6 77.6 79.3 78.4 0.667
  ≥6 22.4 20.7 21.6  
Duration of mealtime, min
  ≤30 58.8 56.7 57.8 0.901
  31 to 59 8.3 9.2 8.7  
  ≥60 32.9 34.1 33.5  
Hold food in the mouth
 Never/rarely 68.0 56.7 62.6 0.015
 Often/always 32.0 43.3 37.4  
Fell asleep when feeding on milk
 Yes 1.8 9.1 5.3 0.001
 No 98.2 90.9 94.7  
Prolonged use of nursing bottle
 Yes 7.5 13.5 10.3 0.040
 No 92.5 86.5 89.7  
Eating before bedtime
 Yes 21.5 37.0 28.9 <0.001
 No 78.5 63.0 71.1  
Consumption of sweet beverage daily
  <1 79.4 71.6 75.7 0.059
  ≥1 20.6 28.4 24.3  
Consumption of candy daily
  <1 80.7 76.0 78.4 0.229
  ≥1 19.3 24.0 21.6  
Consumption of sweet snack daily
  <1 52.6 37.5 45.4 0.002
  ≥1 47.4 62.5 54.6  
Parental toothbrushing
  Twice daily 47.4 39.9 43.8 <0.014
  Once daily 50.0 51.4 50.7  
 Irregular 2.6 8.7 5.5  
Toddler toothbrushing
  Twice daily 54.8 40.9 48.2 <0.001
  Once daily 42.6 38.0 40.3  
 Irregular 2.6 21.1 11.5  
Use of fluoride toothpaste
 Yes 70.5 49.3 60.1 <0.001
 No 29.5 50.7 39.9  

Values are presented as percentages.

a
Chi-square test.

Multiple logistic regression was performed to investigate
the relationships between selected study factors and the pres-
ence of ≥25% VP and ≥5% MS. The same modeling approach
as described earlier was adopted. The significance level for all
analyses was set at 0.05 and analyzed with SPSS for Windows
26.0 (IBM).
Results
A total of 580 families participated in this clinical trial: 294 in
the test group and 286 in the control group. At the 3-y-old tod-
dler follow-up, 436 families (test, n = 228; control, n = 208)
completed the data collection (75.2%; Appendix Fig. 1).
At baseline, there was no significant difference in the
sociodemographic background between the groups (all
P > 0.05; Table 1). The mean ages of fathers and mothers were
33.6 y (SD = 5.1) and 31.7 y (SD = 4.0), respectively. The mean
gestational week was 14.4 (SD = 2.5). More than 60% of the
fathers and mothers had at least tertiary education.
Approximately two-thirds (62.8%) of the families had a house-
hold income ≥$30,000.
There were more boys than girls (55.7% vs. 44.3%).
Toddlers’ mean weight in the test group was significantly
higher than in the control group (16.1 kg vs. 15.5 kg), while the
other characteristics had no significant difference between
groups (all P > 0.05; Appendix Table 1).
Toddlers in the test group had more favorable dietary and
feeding habits than the control group: a significantly lower
proportion of these toddlers held food in the mouth, fell asleep
when feeding with milk, had prolonged use of nursing bottle,
ate before bedtime, and consumed a sweet snack more than
once daily (all P < 0.05; Table 2). The test group also showed
6 Journal of Dental Research 00(0)

Table 3.  Oral Health Outcomes of Study Toddlers from Age 1 to 3 y.

1 y (n = 441) 2 y (n = 424) 3 y (n = 436)

Test Group Control Group Test Group Control Group Test Group Control Group
  (n = 223) (n = 218) P Value (n = 216) (n = 208) P Value (n = 228) (n = 208) P Value

Children with VP  
 Yes 18.8 53.7 <0.001a 39.8 68.8 <0.001a 43.0 71.2 <0.001a
 No 81.2 46.3 60.2 31.3 57.0 28.8  
Teeth with VP, % – – – 8.9 ± 15.7 16.3 ± 17.6 <0.001b 13.6 ± 20.0 27.5 ± 25.5 <0.001b
Children with  
WSL
 Yes 6.7 14.7 0.007a 12.5 24.5 0.001a 24.6 44.7 <0.001a
 No 93.3 85.3 87.5 75.5 75.4 55.3  
Teeth with – – – 0.4 ± 1.5 0.8 ± 2.1 0.027b 0.5 ± 1.2 1.2 ± 1.7 <0.001b
WSL, %
Children with CL  
 Yes 0.0 0.0 – 0.9 1.0 0.970a 4.4 21.2 <0.001a
 No 0.0 0.0 99.1 99.0 95.6 78.8  
Teeth with CL, % – – – 0.02 ± 0.19 0.03 ± 0.31 0.679b 0.1 ± 0.7 0.5 ± 1.2 <0.001b
Distribution  
of MS, %
 0 36.3 33.5 <0.001a 1.9 0.0 <0.001a 0.0 0.0 <0.001a
  <0.1 42.2 16.1 54.2 26.9 50.0 18.3  
  <1 15.2 33.5 6.0 4.3 10.5 7.2  
  <5 6.3 16.0 18.5 22.6 14.9 11.1  
  <20 0.0 0.9 10.2 30.3 14.1 34.1  
  <50 0.0 0.0 4.6 8.2 7.0 22.6  
  ≥50 0.0 0.0 4.6 7.7 3.5 6.7  
MS  
 Ratio 0.2 ± 0.5 0.7 ± 1.3 <0.001b 6.1 ± 15.7 11.6 ± 17.8 0.001b 6.5 ± 15.0 15.3 ± 18.0 <0.001b
 CFU ×104 0.3 ± 0.8 0.5 ± 2.1 0.17b 3.9 ± 13.4 6.7 ± 15.1 0.047b 8.5 ± 38.8 23.5 ± 86.2 0.022b

Values are presented as mean ± SD or percentage. Dashes indicate not applicable.

CFU, colony-forming units; CL, cavitated lesion; MS, Streptococcus mutans; VP, visible plaque; WSL, white spot lesion.
a
Chi-square test.
b
Two-sample t test.

better oral hygiene practices than the control group: a signifi-
cantly higher proportion of toddlers brushed their own teeth
twice daily, were brushed by their parents twice daily, and used
fluoride toothpaste (all P < 0.001).
From age 1 to 3 y, the presence and amount of VP, white
spot lesion, CL, and MS increased over time (Table 3).
However, toddlers in the test group had significantly better oral
hygiene and oral health status throughout follow-ups except
for colony-forming units of MS at age 1 y (P = 0.176) and pres-
ence and number of CL at age 2 y (P = 0.970 and 0.679,
respectively).
At age 3 y, the amount of VP, white spot lesion, and MS in
the test group (13.6%, 0.5, and 6.5%, respectively) was about
40% to 50% of that in the control group (27.5%, 1.2, and
15.3%; all P < 0.001). The prevalence and mean number of CL
in the test group (4.4% and 0.1) were only about one-fifth that
of the control group (21.2% and 0.5; both P < 0.001).
Results from the regression models showed that toddlers in
the control group were at least twice as likely to have CL (inci-
dence rate ratio, 2.87) and ≥25% VP (odds ratio, 2.24) and 4
times as likely to have ≥5% MS colonization (odds ratio, 4.13)
than those in the test group (all P < 0.001; Table 4).
In the model of CL, toddlers whose teeth were brushed by
their parents at age 1 y, those who were breastfed <24 mo, those
who stopped feeding milk with a nursing bottle and did not eat
before bedtime at age 2 y, as well as those who consumed candy
less than once daily at age 3 y had fewer teeth with CL (all
P < 0.01). In the model of VP, toddlers who started brushing their
teeth at age 2 y and those who did not eat before bedtime, con-
sumed sweet beverage less than once daily, received parental
toothbrushing twice daily, and used fluoride toothpaste at age 3
y were less likely to have ≥25% VP (all P < 0.05). Furthermore,
toddlers who consumed candy less than once daily and received
parental toothbrushing twice daily at age 2 y were less likely to
have ≥5% MS colonization (both P < 0.005).
Discussion
The main findings of this clinical trial showed that family-cen-
tered oral health promotion with behavioral and educational
counseling was superior in improving the feeding habits and
early establishment of twice-daily routine parental toothbrush-
ing for toddlers than pamphlet distribution. The guidance pro-
vided in this study helped to reduce the accumulation of VP,
Effectiveness of Family-Centered Oral Health Promotion 7

Table 4.  Final Negative Binomial Regression Model on Number of Teeth the acquisition of MS, and the risk of ECC, thereby preventing
With Cavitated Lesion in Toddlers (3 y) and Multiple Logistic Regression and minimizing the need for invasive treatment for dental car-
Models on VP Level and MS Level.
ies of 3-y-old toddlers.
No. of Cavitated Lesions (n = 383) IRR (95% CI) P Value To the best of our knowledge, this is the first clinical ran-
Group   domized controlled trial on oral health promotion to first-time
  Control group 2.87 (1.74 to 4.74) <0.001 pregnant mothers, their husbands, and infants conducted in
  Test groupa 1.00   Hong Kong. There are very few randomized clinical trials, if
At 1-y-old infant follow-up   any, on oral health promotion started from the prenatal stage to
Parental toothbrushing   the first 3 y of childhood. This study provides evidence that
 No 2.86 (1.69 to 4.76) <0.001 early family-centered oral health promotion with behavioral
 Yesa 1.00  
and educational counseling was superior to distribution of
At 2-y-old toddler follow-up  
Duration of breastfeeding, mo   OHE pamphlets alone in establishing proper feeding habits and
  <24 0.26 (0.14 to 0.47) <0.001 parental toothbrushing practices for toddlers, thereby reducing
  ≥24a 1.00   the accumulation of VP, the acquisition of MS, and the risk of
Feeding milk with nursing bottle   ECC.
 No 0.50 (0.30 to 0.83) 0.008 The prevalence of CL among the study toddlers at ages 2
 Yesa 1.00  
and 3 y was very low (1% and 12.4%) as compared with previ-
Eat before bed  
 No 0.51 (0.31 to 0.84) 0.009
ous Hong Kong studies (Chan et al. 2002; Jiang et al. 2014),
 Yesa 1.00   and no CL was detected at age 1 y. The prevalence of ECC
At 3-y-old toddler follow-up   among 1- to 3 y-olds ranged from 3% in Boston (Nunn et al.
Consumption of candy   2009) to 26% in Japan (Takehara et al. 2013), 28% in
  <1 daily 0.26 (0.16 to 0.42) <0.001 Guangzhou (China; Zhou et al. 2010), and 32% in Sri Lanka
  ≥1 dailya 1.00   (Kumarihamy et al. 2011). Present study results suggest that
VP Level (n = 392) OR (95% CI) P Value the critical period of ECC development would be between ages
2 and 3 y. Thus, implementing timely anticipatory OHE to
Group  
  Control group 2.24 (1.32 to 3.81) 0.003 pregnant women and their husbands is important in promoting
  Test groupa 1.00   toddlers’ oral health.
At 2-y-old toddler follow-up   A recent systematic review found that daily toothbrushing
Toddlers start toothbrushing   and VP were the 2 most important caries risk indicators
 Yes 0.30 (0.14,0.64) 0.002 (Kirthiga et al. 2019). Our study showed that when compared
 Noa 1.00  
with parents who received just the OHE pamphlets, parents
At 3-y-old toddler follow-up  
Eat before bed  
who received individualized OHE in phases (i.e., at different
 No 0.54 (0.31 to 0.95) 0.034 time points) and counseling acquired more effective tooth-
 Yesa 1.00   brushing skills for removal of dental plaque, and as a result
Consumption of sweet beverage   their toddlers had lower levels of VP and ECC. This indicates
  <1 daily 0.31 (0.17 to 0.56) <0.001 the success and effectiveness of individualized OHE for par-
  ≥1 dailya 1.00   ents in promoting toddlers’ oral hygiene and oral health
Parental toothbrushing  
(Parisotto et al. 2010; Douglass and Clark 2015).
  ≥2 times daily 0.35 (0.20 to 0.64) 0.001
  <2 times daily 1.00   Parental toothbrushing and toddler feeding practices were bet-
Use of fluoride toothpaste   ter in this study in both groups (with better practice in the test
 Yes 0.52 (0.31 to 0.89) 0.016 group) than in earlier Hong Kong studies (Chan et al. 2002; Hong
 Noa 1.00   Kong Health Department 2013; Jiang et al. 2014). These out-
MS Level (n = 391) OR (95% CI) P Value comes may indicate that the OHE delivered in both study groups
had a positive impact on the parents’ behaviors. Despite this, the
Group  
feeding habits of the toddlers in this study can be improved, espe-
  Control group 4.13 (2.64 to 6.46) <0.001
  Test groupa 1.00  
cially on sugar control. The sugar intake rates were still high in
At 2-y-old toddler follow-up   both groups, and parents expressed the difficulties and barriers in
Consumption of sweet beverage   controlling the sugar consumption for their toddlers. It remains
  <1 daily 0.34 (0.17 to 0.68) 0.002 an ongoing challenge for OHE to address such issues.
  ≥1 dailya 1.00   One novelty of this study is the measurement of MS, which
Parental toothbrushing   has not been reported in other OHE trials (Riggs et al. 2019).
  ≥2 times daily 0.46 (0.29 to 0.73) 0.001
MS is the principal bacterial species that initiates dental caries
  <2 times dailya 1.00  
(Parisotto et al. 2010), and the association between dental caries
VP level: ≥25%, 1; <25%, 0. MS level: ≥5%, 1; <5%, 0. and MS colonization in plaque has been demonstrated
IRR, incidence rate ratio; MS, Streptococcus mutans; OR, odds ratio; VP, (Straetemans et al. 1998; Kirthiga et al. 2019). According to
visible plaque.
a
Reference group.
previous studies, the earlier that MS is detected in a child’s oral
8 Journal of Dental Research 00(0)
cavity, the greater the risk of ECC development (Seki et al.
2003; Parisotto et al. 2010). Our study showed similar results,
which indicate that ECC risk increased with plaque MS levels.
This emphasizes the importance of good oral hygiene practices
for toddlers to control MS colonization and ECC development.
This study used a life course approach to find out the rela-
tionships of oral health outcomes and their associated factors.
The findings help to explain how dental caries in toddlers
develops over the early childhood period and to identify how
dietary and feeding habits and oral hygiene practices affect
such development.
Due to the low response rate in recruitment and follow-up,
the baseline recruitment criteria and the first follow-up at 32
gestational weeks were correspondingly relaxed to 10 to 22 wk
and the third trimester (beyond 28 wk and before the delivery of
the baby). There were 2 limitations in the present study. First,
the study participants were relatively well educated and had a
high income (Hong Kong Census and Statistics Department
2012), which may explain the better oral health of their toddlers
than the general Hong Kong preschool child population. As
such, the study findings could not be directly extrapolated to the
low socioeconomic groups. Second, the improved oral hygiene
habits of the toddlers in the control group may be attributed to
the Hawthorne effect commonly observed in clinical research
(McCambridge et al. 2014)—that is, families in the control
group were more willing to improve their behaviors because
they were under observation by the researchers.
Conclusion
Family-centered oral health promotion and individualized
OHE for parents via a behavioral and educational counseling
approach are more effective in establishing good feeding hab-
its and parental toothbrushing practices and in decreasing the
caries risk of their toddlers than the distribution of OHE pam-
phlets alone.
Author Contributions
K.F. Yu, contributed to data acquisition, analysis, and interpretation,
drafted and critically revised the manuscript; W. Wen, P. Liu, con-
tributed to data acquisition, analysis, and interpretation, critically
revised the manuscript; X. Gao, E.C.M. Lo, contributed to concep-
tion and design, critically revised the manuscript; M.C.M. Wong,
contributed to conception, design, data acquisition, analysis, and
interpretation, critically revised the manuscript. All authors gave
final approval and agree to be accountable for all aspects of the work.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was supported by a research grant HKU782213M from the
Research Council of Hong Kong SAR, China.
ORCID iDs
P. Liu https://orcid.org/0000-0001-9185-2476
X. Gao https://orcid.org/0000-0002-9930-2476
E.C.M. Lo https://orcid.org/0000-0002-3618-0619
M.C.M. Wong https://orcid.org/0000-0002-7899-1460
References
American Academy of Pediatric Dentistry. 2016. Guideline on caries-risk
assessment and management for infants, children, and adolescents. Pediat
Dent. 38(6):142–149.
American Academy of Pediatric Dentistry. 2018a. Guideline on periodicity of
examination, preventive dental services, anticipatory guidance/counseling,
and oral treatment for infants, children, and adolescents. In: The refer-
ence manual of pediatric dentistry. Chicago (IL): American Academy of
Pediatric Dentistry. p. 232–241.
American Academy of Pediatric Dentistry. 2018b. Policy on the dental home.
In: The reference manual of pediatric dentistry. Chicago (IL): American
Academy of Pediatric Dentistry. p. 43–44.
Chan SCL, Tsai JSJ, King NM. 2002. Feeding and oral hygiene habits of pre-
school children in Hong Kong and their caregivers’ dental knowledge and
attitudes. Int J Paediatr Dent. 12(5):322–331.
Chen KJ, Gao SS, Duangthip D, Li SKY, Lo ECM, Chu CH. 2017. Dental car-
ies status and its associated factors among 5-year-old Hong Kong children:
a cross-sectional study. BMC Oral Health. 17(1):121.
Chu CH, Ho PL, Lo ECM. 2012. Oral health status and behaviours of preschool
children in Hong Kong. BMC Public Health. 12:767.
Douglass JM, Clark MB. 2015. Integrating oral health into overall health care
to prevent early childhood caries: need, evidence, and solutions. Paediatr
Dent. 37(3):266–274.
Gentra Systems. 2014. Gentra Puregene handbook. 4th ed. Qiagen. https://web
.emmes.com/study/hbb/public/EN-Gentra-Puregene-Handbook-2014.pdf
[accessed 2020 Jan 7].
Hong Kong Census and Statistics Department. 2012. Trends in population
and domestic households in Hong Kong. https://www.censtatd.gov.hk/
en/data/stat_report/product/FA100119/att/B71204FA2012XXXXB01.xls
[accessed 2020 Nov 12].
Hong Kong Health Department. 2013. Oral health survey 2011. https://www
.toothclub.gov.hk/en/en_pdf/Oral_Health_Survey_2011/Oral_Health_
Survey_2011_WCAG_20141112_(EN_Full).pdf [accessed 2020 Nov
12].
Ismail AI, Sohn W, Tellez M, Willem JM, Betz J, Lepkowski J. 2007. Risk
indicators for dental caries using the International Caries Detection
and Assessment System (ICDAS). Community Dent Oral Epidemiol.
36(1):55–68.
Jiang EM, Lo ECM, Chu CH, Wong MCM. 2014. Prevention of early child-
hood caries (ECC) through parental toothbrushing training and fluoride
varnish application: a 24-month randomized controlled trial. J Dent.
42(12):1543–1550.
Kirthiga M, Murugan M, Saikia A, Kirubakaran R. 2019. Risk factors for early
childhood caries: a systematic review and meta-analysis of case control and
cohort studies. Paediatr Dent. 41(2):95–112.
Kumarihamy SL, Subasinghe LD, Jayasekara P, Kularatna SM, Palipana PD.
2011. The prevalence of early childhood caries in 1-2 yrs olds in a semi-
urban area of Sri Lanka. BMC Res Notes. 4:336.
Lantz CA, Nebenzahl E. 1996. Behavior and interpretation of the κ statistic:
resolution of the two paradoxes. J Clin Epidemiol. 49(4):431–434.
Leong PM, Gussy MG, Barrow SYL, de Silva-Sanigorski A, Waters E. 2012.
A systematic review of risk factors during first year of life for early
­childhood caries. Int J Paediatr Dent. 23(4):235–250.
Liu P, Wen W, Yu KF, Gao X, Lo ECM, Wong MCM. 2020. Effectiveness
of a family-centered behavioral and educational counselling approach to
improve periodontal health of pregnant women: a randomized controlled
trial. BMC Oral Health. 20(1):284.
Lo ECM, Kwok EYL, Lee CK. 2009. Dental health status of Hong Kong pre-
school children. Hong Kong Dent J. 6:6–12.
Martins-Júnior PA, Vieira-Andrade RG, Corrêa-Faria P, Oliveira-Ferreira F,
Marques LS, Ramos-Jorge ML. 2013. Impact of early childhood caries on
the oral health-related quality of life of preschool children and their parents.
Caries Res. 47(3):211–218.
McCambridge J, Witton J, Elbourne DR. 2014. Systematic review of the
Hawthorne effect: new concepts are needed to study research participation
effects. J Clin Epidemiol. 67(3):267–277.
Effectiveness of Family-Centered Oral Health Promotion 9
Nunn ME, Dietrich T, Singh HK, Henshaw MM, Kressin NR. 2009. Prevalence
of early childhood caries among very young urban Boston children com-
pared with US children. J Public Health Dent. 69(3):156–162.
Oral Health Education Division. n.d. Oral health care for your children. Hong
Kong Health Department. https://www.toothclub.gov.hk/pdf/en_B054-03/
en_B054-03_Page_00.html [accessed 2021 Jun 24].
Parisotto TM, Steiner-Carolina C, Silva CMSE, Rodrigues LKA, Nobre dos-
Santos M. 2010. Early childhood caries and mutans streptococci: a system-
atic review. Oral Health Prev Dent. 8(1):59–70.
Riggs E, Kilpatrick N, Slack-Smith L, Chadwick B, Yelland J, Muthu MS,
Gomersall JC. 2019. Interventions with pregnant women, new mothers and
other primary caregivers for preventing early childhood caries. Cochrane
Database Syst Rev. 2019(11):CD012155.
Seki M, Karakama F, Terajima T, Ichikawa Y, Ozaki T, Yoshida S, Yamashita
Y. 2003. Evaluation of mutans streptococci in plaque and saliva: correla-
tion with caries development in preschool children. J Dent. 31(4):283–290.
Straetemans MME, van Loveren C, de Soet JJ, de Graaff J, ten Cate JM. 1998.
Colonization with mutans streptococci and lactobacilli and the caries expe-
rience of children after the age of five. J Dent Res. 77(10):1851–1855.
Takehara S, Ueno M, Kawaguchi Y. 2013. Japanese national dental surveys
on pre-school children. https://iadr.abstractarchives.com/abstract/wcpd13-
182620/japanese-national-dental-surveys-on-pre-school-children [accessed
2020 Nov 12].
Wong MCM, Lu HX, Lo ECM. 2012. Caries increment over 2 years in
­p reschool children: a life course approach. Int J Pediatr Dent. 22(2):
77–84.
World Health Organization. 2013. Oral health surveys: basic methods. Geneva
(Switzerland): World Health Organization.
World Health Organization. 2016. WHO expert consultation on public health
intervention against early childhood caries. p. 26–28. https://apps.who
.int/iris/bitstream/handle/10665/255627/WHO-NMH-PND-17.1-eng
.pdf?sequence=1 [accessed 2020 Nov 12].
Yu KF. 2020. Effectiveness of family-centered oral health promotion on
infant oral health [thesis]. University of Hong Kong. https://hub.hku.hk/
handle/10722/282046 [accessed 2021 Jul 14].
Zhou Y, Lin HC, Lo ECM, Wong MCM. 2010. Risk indicators for early
childhood caries in 2-year-old children in southern China. Aust Dent J.
56(1):33–39.