Parental knowledge, attitudes and cultural beliefs
regarding oral health and dental care of preschool
children in an Indian population: a quantitative study
N. Chhabra*, A. Chhabra**
*Department of Pedodontics, Krishna Dental College, Ghaziabad, Uttar Pradesh, India.
**Department of Dental Surgery, Safdarjang Hospital, Delhi, India.
Key words: Preschool children, parental attitudes,
knowledge, cultural beliefs, oral health
Postal address: Dr N. Chhabra, Department of Pedodontics, Krishna
Dental College, Ghaziabad, Uttar Pradesh, India.
Email: nidhimahajandr84@gmail.com
Abstract
AIM: Preschool children are dependent upon their par-
ents for their dental care. The aim of this study was to
assess the knowledge, attitude and beliefs of parents
towards oral health and dental care of their children aged
1-4 years in an Indian population. METHODS: Parents of
620 preschool children, who visited Krishna Dental Col-
lege and Hospital, Ghaziabad, India for dental treatment
were recruited into this study and completed a self-
administered questionnaire. RESULTS: It was revealed
that the lack of knowledge and awareness of importance
of the primary teeth, dental fear of the parents and the
myths associated with dental treatment, created barri-
ers to early preventive dental care of preschool children.
The oral hygiene and feeding practices were found to be
disappointing and the knowledge about the essential role
VM Å\VYPKL HUK [YHUZTPZZPVU VM :[YLW[VJVJJ\Z T\[HUZ
bacteria was found to be limited. The elders in the family,
LZWLJPHSS` NYHUKWHYLU[Z OPNOS` PUÅ\LUJLK [OL KLJPZPVUZ
of the parents regarding dental treatment of their children.
CONCLUSIONS: Parents’ knowledge, attitudes and
beliefs about the importance of dental health need to be
PTWYV]LK*VVYKPUH[LKLɈVY[ZI`WHLKPH[YPJPHUZWHLKPH[-
ric dentists and other health professionals are required to
impart dental health education about oral hygiene, feed-
ing practices, importance of the primary dentition and to
promote preventive dental programmes.
Introduction
+L]LSVWLK JV\U[YPLZ OH]L YLJVYKLK H ZPNUPÄJHU[ KLJSPUL PU
the severity and prevalence of oral diseases among their
WVW\SH[PVUZV]LY[OLSHZ[Ä]LKLJHKLZVM[OL[^LU[PL[OJLU-
tury [Davies et al., 1997]. The credit goes to the education
promotional programs regarding oral hygiene, diet and feed-
ing practices and programs that encourage early access to
professional preventive dental care. Unfortunately devel-
oping countries, such as India face many challenges in
rendering oral health needs of preschool children, especially
in rural populations [Pine et al., 2004; Grewal et al., 2007].
6YHSOLHS[OVM[OLWYLZJOVVSJOPSKYLUPZHɈLJ[LKI`WHYLU[HS
dental knowledge, attitudes, cultural beliefs and awareness
about infant diet and feeding practices, oral hygiene habits,
76 European Archives of Paediatric Dentistry 13 (Issue 2). 2012
preventive regular dental visits, care of primary teeth and
concern for oral health [Okada et al., 2002; Wong et al.,
2005]. Knowledge and awareness are necessary prerequi-
sites for changes in behaviour, including behaviour related
to health and disease prevention [Green and Kreuter, 1999].
There is a paucity of literature available regarding parental
knowledge, attitudes and cultural beliefs regarding oral
health of their children in developing countries such as India.
Moreover, most of those surveys reported in the literature
are targeted at school age children due to easy accessibil-
ity, which is not possible in preschool children [Holm, 1990].
Consequently, this study was carried out to investigate how
the dental health attitudes, knowledge and cultural beliefs
VM0UKPHUWHYLU[ZHɈLJ[LK[OLVYHSOLHS[OVM[OLPYWYLZJOVVS
children and to formulate data for the prospect of future
research.
Methods
Study population and sampling method. A quantitative
research methodology was used to collect data on paren-
tal attitudes, their knowledge towards child dental care
HUKJ\S[\YHSILSPLMZHɈLJ[PUN[OLKLU[HS[YLH[TLU[;OLWHY-
ticipants were the parents (primary caregivers), of children
aged between 1-4 years who reported for dental treatment
in the Department of Paedodontics and Preventive Dentistry,
Krishna Dental College and Hospital, Ghaziabad, India. The
study population lived in both rural and urban communities.
A total of 653 parents agreed to participate in the study,
whose age ranged between 24-30 years. The parents were
requested to complete a comprehensive questionnaire com-
prising of a small set of pre-selected topics or questions
(Table 1) adopted from oral health literature [Peterson et
al., 2000; Stenberg et al., 2000] and chosen based on the
researcher’s knowledge or experience of the issues under
study, on the following:
1. Oral hygiene habits (frequency, duration, time and brush-
ing aids used),
2. Role of the parents in the children’s oral hygiene and
dental education,
3. Diet and feeding patterns of their children,
4. Assessment of parent’s knowledge of oral health
and dental problems,
5. Parental attitude and opinion towards dentists and
dental care,
6. Awareness of the parents regarding dental treatment and
regular dental visits,
7. Cultural beliefs of the parents and their families and social
PUÅ\LUJLZ [OH[ HɈLJ[LK [OL WHYLU[Z KLJPZPVU YLNHYKPUN
dental treatment.
 Parental knowledge of OH care of Indian preschool children

Subjects were advised how to respond to each question Table 1. The questionnaire that was completed by a sample of
by choosing one or more responses from a provided list of parents of the preschool children in india.

options, by writing in the response, or performing a combina-

1. /V^VM[LUHKH`KVLZ`V\YJOPSKIY\ZOOPZOLY[LL[O&
tion of the two. The subjects received a full explanation of how
to score their responses. The questionnaire was translated 2. >OH[KVLZOLZOL\ZLMVYJSLHUPUNOPZOLY[LL[O&
into the local language for better understanding by the sub-
3. What is the role played by you in your child’s oral hygiene
jects, and they were asked to approach the investigator for HUKKLU[HSLK\JH[PVU&
JSHYPÄJH[PVUPM[OLYL^LYLHU`KV\I[Z;OLZ\IQLJ[Z^LYLMYLL
to choose more than one answer for the same question, for 4. +VLZIY\ZOPUN[OL[LL[OWYL]LU[KLU[HSWYVISLTZ&
some items. This explains why the numbers in the frequency
5. (YL[OLWYPTHY`[LL[OPTWVY[HU[&
columns of the tables in the results section sometimes did not
equal the total sample number for those items. 6. >OH[PZ[OLW\YWVZLVM[OLÄYZ[ZL[VM[LL[O&

Most of the parents took 30-40 minutes to complete the ques- 7.
tionnaire. Positive reinforcement was performed at the end of
8.
the interview for the cooperative behaviour of the subjects and
NPM[Z Z\JO HZ [VV[OIY\ZOZ [VV[OWHZ[L ÅVZZ L[J ^LYL KPZ- 9.
tributed to each participant. The quantitative research study
*HUWYVISLTZVMWYPTHY`[LL[OHɈLJ[[OLWLYTHULU[[LL[O&
/V^MYLX\LU[S`KVLZ`V\YJOPSK[HRLZ^LL[Z&
+VLZMYLX\LU[L_WVZ\YL[VZ^LL[HUKZ[PJR`MVVKZHɈLJ[
KLU[HSOLHS[O&

lasted for a period of 24 weeks. Descriptive statistics were 10. +VLZWYVSVUNLKHUKMYLX\LU[IV[[SLMLLKPUNHɈLJ[

obtained and percentage frequency distributions of parental
responses to questions were calculated. Study data was ana-
11.
lysed using SPSS (version 13.0) (SPSS Inc., Chicago, Ill.).
12.
Results
13.
Out of the total study population of 653 parents, 595 decided
to participate immediately. Fifty eight parents indicated that
14.
they were interested in receiving more information before
deciding to participate. Of these, 25 parents agreed to partici-
15.
pate in the project while 33 parents refused to participate and
were eliminated from the study. A total of 620 parents returned
the completed questionnaires, accounting for a response rate 16.
VM  WLYJLU[;OLÄUHSZ[\K`ZHTWSLPUJS\KLKMLTHSL
17.
KLU[HSOLHS[O&
0ZP[ÄUL[VW\[IHI`[VILK^P[OHIV[[SL&
+VLZÅ\VYPKLWYL]LU[[OLKLJH`VM[OL[LL[O&
Do bacteria causing decay get transmitted from parents
[VJOPSKYLU&
Whether general body health has a relationship to oral
OLHS[OVYUV[&
Does your family care about the teeth as much as any part
VM`V\YIVK`&
/V^MYLX\LU[S`KV`V\]PZP[`V\YKLU[PZ[&
>OL[OLYYLN\SHY]PZP[Z[V[OLKLU[PZ[HYLULJLZZHY`VYUV[&
WHYLU[ZHUKTHSLWHYLU[Z
18.
Parental knowledge and awareness regarding oral hygiene
habits. Results of the parental questionnaire regarding oral
19.
What was the reason for the last visit of your child to
[OLKLU[PZ[&
What treatment(s) did your child require during the last
O`NPLULWYHJ[PJLZYL]LHSLK[OH[VM[OLWYLZJOVVSJOPS-
]PZP[[V[OLKLU[PZ[&
KYLU^LYLIY\ZOPUN[OLPY[LL[OVM[OLZ\IQLJ[ZYLWVY[LK
the use of toothbrush and toothpaste to clean their children’s 20. When do you feel is the best time to take your youngest
JOPSK[V[OLKLU[PZ[&
[LL[O^OPSL\ZLKÄUNLYHUK[VV[OWHZ[LWV^KLYMVYVYHS
JSLHUPUN (IV\[  VM [OL Z\IQLJ[Z KLZJYPILK [OL \ZL VM 21. What have been some of your personal experiences going
KLU[HSÅVZZYLWVY[LK[OL\ZLVMTV\[O^HZOHUK [V[OLKLU[PZ[&
stated that their children were using toothpicks as an extra aid 22. /V^OH]L`V\YV^UL_WLYPLUJLZH[[OLKLU[PZ[PUÅ\LUJLK
MVYVYHSO`NPLUL4VZ[VM[OLYLZWVUKLU[ZZ[H[LK[OH[ `V\YKLJPZPVU[V[HRL`V\Y`V\UNLZ[JOPSK[V[OLKLU[PZ[&
[OLPYJOPSKYLUIY\ZOLK[OLPY[LL[OVUS`VUJLKHPS`^OPSL
23. (YL[OLYLV[OLYWLVWSL^OVPUÅ\LUJL`V\YKLU[HSJHYL
brushed twice daily or more (Table 2). KLJPZPVUZ[HRLUMVY`V\YJOPSK&
Approximately one-half of the parents interviewed said that
brushing the teeth of children under the age of two years was
not done at all or was performed occasionally. A child of 3-4
years was anticipated to start brushing his or her own. It was
HZ[VUPZOPUN [V ÄUK [OH[   VM [OL WHYLU[Z PU [OPZ Z[\K`
never watched the brushing technique of their children nor
gave them any brushing instructions.

European Archives of Paediatric Dentistry 77

 N. Chhabra, A. Chhabra

Table 2. Parental knowledge and awareness of regarding Table 3. Parental knowledge and awareness of regarding oral
VYHSO`NPLULOHIP[ZU$PUHZHTWSLVM0UKPHUWHYLU[Z HUKIVK`OLHS[OU$PUHZHTWSLVM0UKPHUWHYLU[Z

Frequency Percentage (%) Frequency Percentage (%)

Oral hygiene aids used Are primary teeth important?
Toothbrush and paste 200 32.3 Yes 194 31.3
Toothbrush and powder 19 3.0 No 400 64.5
Finger and paste/powder 85 13.7 Don’t know 26 4.2
Datun and wooden sticks 11 1.8 *HUWYVISLTZVMWYPTHY`[LL[OHɈLJ[[OLWLYTHULU[[LL[O&
Mouthwash 6 1.0 Yes 201 32.4
+LU[HSÅVZZ 8 1.3 No 286 46.1
None of the above 291 46.9 Don’t know 133 21.5
Frequency of tooth brushing +VLZMYLX\LU[L_WVZ\YL[VZ^LL[HUKZ[PJR`MVVKZHɈLJ[
dental health?
Once daily 256 41.3
Yes 435 70.2
Twice daily 65 10.5
No 151 24.3
More than twice daily 8 1.3
Don’t know 34 5.5
Occasionally or never 291 46.9
+VLZWYVSVUNLKHUKMYLX\LU[IV[[SLMLLKPUNHɈLJ[
Role of parents in supervision and guidance of oral hygiene dental health?
Parents observe and guide 226 36.5 Yes 162 26.1
Parents only advise but 147 23.7 No 432 69.6
don’t monitor
Don’t know 26 4.3
Parents did not bother 247 39.8
0ZP[ÄUL[VW\[IHI`[VILK^P[OHZ^LL[LULKTPSRIV[[SL&
Yes 373 60.2
6US`VM[OLZ\IQLJ[ZZ[H[LK[OH[[OL`VIZLY]LKHUKN\PKLK No 183 29.5
[OLPYJOPSKYLUK\YPUNIY\ZOPUN^OPSLYLWVY[LKNP]PUNHK]PJL Don’t know 64 10.3
on the importance of brushing but did not monitor the children
+VLZÅ\VYPKLWYL]LU[[VV[OKLJH`&
(Table 2).
Yes 187 30.1
Parental knowledge and awareness regarding oral and No 156 25.2
body health. (IV\[  VM [OL Z\IQLJ[Z KLUPLK [OL MHJ[
Don’t know 277 44.7
that treatment for decayed primary teeth was essential as
Do bacteria causing decay get transmitted from parents
they believed that primary teeth were not as important as the
to children?
WLYTHULU[ [LL[O 9LZWVUZLZ YLJVYKLK PU ;HISL  YLÅLJ[LK
Yes 61 9.8
that most caregivers did not believe that problems of primary
[LL[OJHUHɈLJ[[OLWLYTHULU[Z\JJLZZVYZHUKVUS` No 144 23.2

of the subjects agreed that oral health could lead to general Don’t know 415 67.0
body health problems (Table 3). +VLZVYHSOLHS[OHɈLJ[NLULYHSIVK`OLHS[O&

4VZ[VM[OLWHYLU[Z^LYLH^HYL[OH[MYLX\LU[PU[HRL Yes 295 47.6

of sweet and sticky foods could cause decay of the teeth No 188 30.3
whereas the awareness of the consequences of prolonged, Don’t know 137 22.1
frequent bottle feeding and the harm caused by nursing bot-
tles at bed time was lacking in the study population. The
YVSLVMÅ\VYPKLPUWYL]LU[PUN[VV[OKLJH`^HZZ\WWVY[LKI`
VUS`VM[OLYLZWVUKLU[Z7HYLU[Z^LYLSHYNLS`\UH^HYL
that bacteria involved in dental caries could be transmitted
[V[OLPYJOPSKMYVT[OLT3LZZ[OHUVMZ\IQLJ[ZHNYLLK
to this fact (Table 3).

78 European Archives of Paediatric Dentistry 13 (Issue 2). 2012

 Parental knowledge of OH care of Indian preschool children

Parental attitudes towards professional dental care and Table 4. Parental attitudes towards professional dental care and
associated cultural beliefs. Few subjects (approximately HZZVJPH[LKJ\S[\YHSILSPLMZU$
YLWVY[LK[OH[[OL`[VVR[OLPYJOPSKYLU[V[OLKLU[PZ[LHYS`
Percentage
in childhood exclusively for prevention. Of the respondents Frequency (%)
LTWOHZPZLK[OLPTWVY[HUJLVMYLN\SHYKLU[HS]PZP[Z^OPSL
How frequently do you visit the dentist?
 VM WHYLU[Z KPZHNYLLK ^P[O [OH[ MHJ[ ;OL H^HYLULZZ
[OH[[OLÄYZ[KLU[HS]PZP[ZOV\SKVJJ\YI`TVU[OZVMHNL Regularly 139 22.4
^HZWYLZLU[PUVUS`VM[OLZ[\K`WVW\SH[PVU;HISL When having pain or in trouble 327 52.8
The main reason for the last dental visit of the children was Sometimes or never 154 24.8
[VV[OHJOL  V[OLY MHJ[VYZ ILPUN [VV[O KLJH`  Are frequent visits to the dentist important?
Z^LSSPUNZ  YLN\SHY KLU[HS L_HTPUH[PVU 
Yes 156 25.2
KLWVZP[Z HUK IHK TV\[O VKV\Y  ;HISL  ;OLZL
results revealed that the most common reason of disliking No 239 38.5
and not visiting the dentist on a regular basis was fear by the Don’t know 225 36.3
WHYLU[Z YLNHYKPUN KLU[HS [YLH[TLU[  6[OLY YLHZVUZ
([^OH[HNLZOV\SK[OLÄYZ[KLU[HS]PZP[VM[OLJOPSKIL
Z[H[LK^LYL[OLOPNOJVZ[VM[YLH[TLU[KPɉJ\S[`VM scheduled?
HJJLZZPIPSP[`[VHJSPUPJZOVY[HNLVM[PTLHUK
>OLU[OLÄYZ[WYPTHY`[VV[OLY\W[Z 94 15.2
J\S[\YHS ILSPLMZ HZZVJPH[LK ^P[O KLU[HS [YLH[TLU[   or before the age of 1 year
>OLUWHYLU[Z^LYLHZRLKPMZVJPHSPUÅ\LUJLZHɈLJ[LK[OLPY
When permanent teeth erupt 302 48.7
KLJPZPVU YLNHYKPUN KLU[HS [YLH[TLU[   VM [OL WHYLU[Z
responded that elders, especially the grandparents, played Don’t know 224 36.1
a crucial role in taking decisions about dental treatment of Reason for the last dental visit of your child:
their grandchildren (Table 4).
Decay 81 13.1

Discussion Pain 250 40.3

Swelling 102 16.5
To our knowledge, this is one of the very few Indian studies
presenting the results of a parental questionnaire designed Deposits and bad odour 32 5.2
to assess the knowledge, attitudes and cultural beliefs of Regular dental check-up 125 20.1
parents regarding the oral health of their preschool children.
Other reasons 30 4.8
0[ZWLJPÄJHSS`MVJ\ZLZVU[OLYLSL]HU[YPZRHUKWYV[LJ[P]LMHJ-
[VYZ[OH[HYLSPRLS`[VOH]LHUPUÅ\LUJLVUVYHSOLHS[OPU[OPZ Reasons behind not visiting the dentist:
age group of the population. A good understanding of paren- Fear factor of parents 342 55.2
tal knowledge, attitudes, beliefs and awareness regarding
High cost of treatment 64 10.3
VYHS OLHS[O PZ LZZLU[PHS MVY [OL LɈLJ[P]LULZZ VM VYHS OLHS[O
WYVTV[PVU LɈVY[Z HPTLK H[ PTWYV]PUN [OL KLU[HS OLHS[O VM +PɉJ\S[`VMHJJLZZPIPSP[`[VJSPUPJ 53 8.6
young children. It has been found that the more positive the Shortage of time 48 7.7
parent’s attitude is towards dentistry, then the better will be Any cultural beliefs associated with 99 15.9
the dental health status of their children [Schroth et al., 2007]. dental treatment

;OPZZ\Y]L`MV\UK[OH[VM[OLJOPSKYLUIY\ZOLK[OLPY 5VZWLJPÄJYLHZVU 14 2.3

[LL[O H[ SLHZ[ VUJL KHPS` 6]LY OHSM   VM [OL WHYLU[Z +V`V\[OPUR[OH[`V\YMLHYMHJ[VYHɈLJ[Z[OLKLU[HS
believed that children were capable of brushing their own treatment of your child?
[LL[OI`[OLHNLVM`LHYZ;OPZYLÅLJ[Z[OLSHJRVMIV[O Yes 231 37.2
parental and child oral health education. It is highly recom-
No 144 23.3
mended that adults perform or assist brushing for young
JOPSKYLU\UKLY[OLHNLVMÄ]L`LHYZHZ[OL`HYLVUS`WHY[PHSS` Don’t know 245 39.5
able to brush their teeth due to lack of dexterity and cogni- (YL[OLYLV[OLYWLVWSL^OVPUÅ\LUJL`V\YKLU[HSJHYL
tion needed for adequate cleaning [Mohebbi et al., 2008]. decisions taken for your child?

The majority of the parents did not brush the teeth of their Yes 370 59.7
children who were under 2 years old because of a lack of No 250 40.3
H^HYLULZZ;OPZPZJVUZPZ[LU[^P[O[OLÄUKPUNZMYVTWYL]PV\Z
studies [Habibian et al., 2001; Suresh et al., 2010] who found
that most of the parents started brushing their children’s
teeth when all the primary teeth had erupted. It was quite

European Archives of Paediatric Dentistry 79

 N. Chhabra, A. Chhabra
Z\YWYPZPUN [V ÄUK [OH[ [OL \ZL VM V[OLY YLJVTTLUKLK VYHS
O`NPLULTL[OVKZZ\JOHZKLU[HSÅVZZHUKTV\[O^HZO^LYL
performed rarely; this could be due to the lack of oral health
education and/or the cost of such aids.
Thus dental health education programs that aim to improve
oral health practices among a population need to be organ-
ised. Parents should be educated that regular tooth cleaning
ULLKZ[VZ[HY[LHYS`PUSPMLHZZVVUHZ[OLÄYZ[WYPTHY`[VV[O
LY\W[ZHUKKLU[HSÅVZZZOV\SKIL\ZLK^OLUHKQHJLU[[LL[O
are touching, as recommended by the American Academy of
Pediatric Dentistry [2011]. Physical demonstration of tooth
brushing techniques to the parents and children and the
use of salient reinforcers may be more valuable than verbal
advice to clean children’s teeth.
The response of the parents here in regarding the role of
frequent intake of sweets and sticky food products in caus-
ing decay was quite encouraging. The results coincided with
previous studies [Lin et al., 2001; Suresh et al., 2010]. On the
contrary, concerning the awareness of parents about baby
bottle use, it was found that more than two-thirds of the
parents continued the use of a nursing bottle at night time
while the child was asleep. This revealed parental ignorance
regarding nursing bottle use and lack of adequate dental
LK\JH[PVU:PTPSHYÄUKPUNZ^LYLYLWVY[LKI`/HSSVUZ[LUL[HS
[1995]. Consequently, dietary advice should be emphasised
by dentists and other health professionals in contact with
expectant mothers as well as mothers of infants.
Fluoride has a protective action against the development
of caries [Davies et al., 2002]. However, it was unfortunate
[V ÄUK [OH[ [OLYL ^HZ H SHJR VM RUV^SLKNL I` [OL WHYLU[Z
YLNHYKPUN[OLYVSLVMÅ\VYPKLPUWYL]LU[PUNKLJH`HIV\[[OL
IHJRNYV\UKSL]LSZVMÅ\VYPKLPU[OLPYKYPURPUN^H[LYHUK[OL
HWWYVWYPH[L\ZLVMÅ\VYPKH[LK[VV[OWHZ[LZ7HYLU[ZULLK[V
IL LK\JH[LK HIV\[ [OL PTWVY[HUJL VM Å\VYPKL HUK VW[PTHS
Å\VYPKLL_WVZ\YLYLX\PYLKMVY[OLPYJOPSKYLU
The practice of kissing their child and sharing foods and
utensils by adults has been associated with early infec-
tion with Streptococcus mutans in infants [Newbrun, 1992;
no connection between the presence of caries in the primary
teeth and subsequent caries in the permanent teeth. A quan-
titative survey of Vietnamese carers of pre-school children in
Canada suggested a lack of parental belief in the importance
of primary teeth [Harrison and Wong, 2003]. In a study of car-
ers in Saipan, it was reported that the low value attributed to
IHI`[LL[O^HZHUVIZ[HJSL[VKL]LSVWPUNLɈLJ[P]LWYL]LU-
tion programs [Riedy et al., 2001].
It was evaluated and clinically correlated that children of the
parents who disagreed that the primary teeth were important,
were more likely to have EEC. New methods of delivering
anticipatory guidance, laying emphasis on the link between
oral health and well-being of the body may be more promis-
ing in changing prevalent attitudes and behaviours about the
primary dentition.
The necessity of regular preventive dental examinations and
treatment was not considered to be important by many of
the patients unlike in developed countries where initiative is
[HRLU I` LP[OLY [OLPY WHYLU[Z VY KLU[PZ[Z :\JO HU LɈVY[ VU
the part of the parents is predominantly missing in Indian
JOPSKYLU B.YL^HS HUK 2H\Y D :PTPSHY ÄUKPUNZ ^LYL
VIZLY]LKPU[OPZZ[\K`;OLÄUKPUNZPU[OPZZ[\K`^LYLZPTPSHY
to that reported by Hilton et al. [2007] who observed that
there was low utilisation of preventive dental services by the
preschool children as the parents did not recognise that den-
tal problems might exist in their child.
Fear of dental treatment, whether derived from prevailing
community beliefs or personal negative dental experiences
was found to be high among the study population of par-
LU[Z ^OV ULNH[P]LS` PUÅ\LUJLK [OL YLN\SHY KLU[HS ]PZP[Z VM
their children and prevented them from receiving routine
dental treatment. Mattila et al. [2000] also reported similar
ÄUKPUNZ PU [OLPY Z[\KPLZ 4PSNYVT L[ HS B D UV[LK [OH[
children with mothers having high levels of personal fear
utilised fewer dental services than children of mothers with
low fear. Dentists can play an important role in eliminating
the fear of parents and children by an empathic approach,
retraining the parental negative behaviours due to previous
:HRHPL[HSD0[^HZZ\YWYPZPUN[VÄUK[OH[VUS` VM
parents knew about the transmission of cariogenic bacteria
from mother to the child, and the fact that it could increase
the risk and severity of caries in very young children. The
ÄUKPUNZ^LYLZPTPSHY[V[OH[YLWVY[LKI`:HRHPL[HSBD
Education of parents is required to reduce the risk of early
transmission of cariogenic bacteria.
It was also found that the lack of knowledge and beliefs
about primary teeth created barriers to early preventive den-
tal care in the study population. The majority of parents were
not aware of the long-term importance of primary teeth. They
believed that primary teeth would remain in the mouth for
only a short period of time and would be replaced ultimately.
Forty-six percent of the parents responded that there was
80 European Archives of Paediatric Dentistry 13 (Issue 2). 2012
experiences and educating parents about the latest preven-
tive dental techniques that minimise discomfort and pain.
Other reasons for not visiting the dentist were cited as high
JVZ[ZVMKLU[HSJHYLKPɉJ\S[`VMHJJLZZPIPSP[`[VKLU[HSJSPU-
ics, shortage of time and cultural beliefs associated with the
dental treatment.
This study revealed that there were many myths associated
with dental treatment, for example, that extraction of teeth
can have a negative impact on vision, scaling of teeth can
cause loosening of teeth, treatment under anaesthesia can
HK]LYZLS`HɈLJ[JOPSKKL]LSVWTLU[HUKTLU[HSJHWHJP[`L[J
A better understanding of these cultural beliefs may help the
KLU[PZ[ZL_WSHPU[OLVIQLJ[P]LZYPZRZHUKILULÄ[ZVMKLU[HS
treatment to the parents [Wong et al., 2005].
 Parental knowledge of OH care of Indian preschool children
The results of this study highlighted that family members,
LZWLJPHSS`NYHUKWHYLU[ZL_LY[LKHJVUZPKLYHISLPUÅ\LUJLVU
taking dental care decisions by parents, mainly the moth-
ers. Similar results were reported by Mattila et al. [2000] and
Wong et al. [2005] in their studies. The suggestions given
by the elders were highly respected although paradoxical
HK]PJL^HZZVTL[PTLZNP]LUI`[OLTHɈLJ[PUN[OLHJJLZ-
sibility to preventive dental care. It was brought to the notice
of the investigators that in many families, elders condemned
the oral hygiene practices and dietary restrictions imposed
on the children by the parents. Dental educational programs
aimed at changing attitudes or beliefs that create potential
barriers to dental treatment access should not only target the
primary carer or parent but should instead provide aware-
ness to the entire family.
The results of this study reveal that multi-disciplinary
approaches to improve preschool oral health are needed.
,HYS`PKLU[PÄJH[PVUVM[OLOPNOYPZRWYLZJOVVSJOPSKPZPUKPZ-
pensable so that appropriate preventive approaches can
be implemented, and anticipatory guidance can be used
[Winter, 1990]. New methodologies, especially motivational
interviewing and the community development approaches
for health promotion are promising and need to be explored
[Harrison and White, 1997; Weinstein et al., 2004].
Preventive strategies should be emphasised in programs
organised for prenatal women and those in preschool and
elementary school settings. In addition, dental education
about oral hygiene practices, diet counselling, importance
of the primary dentition and regular dental visits need to be
given [Blinkhorn, 1981; Adair et al., 2004; Finlayson et al.,
2005]. Paediatric dentists and paediatricians should also
guide and support public campaigns to reach parents lack-
ing in knowledge of oral health care.
This study has limitations. Every population group has
variations in beliefs and practices by socio-economic sta-
tus, education level, religion, etc. Those determinants to a
child’s oral health were not considered in this study. Also
data reported in this study cannot be generalised to the
entire Indian population. Further quantitative and qualitative
research studies on a larger sample and for a longer period
are essential for the better understanding of the knowledge,
attitudes and awareness of parents about preschool oral
OLHS[OHUK[OL]HYPV\ZMHJ[VYZ[OH[PUÅ\LUJL[OLT(JJ\YH[L
assessment of caregivers' knowledge and perceptions about
children's oral health can aid in the planning and implemen-
tation of tailored educational and cognitive-behavioural
interventions [Finlayson et al., 2005].
Conclusions
;OLYLPZHULLKMVYPU[LUZP]LJVVYKPUH[LKLɈVY[ZI`WHLKPH[YP-
cians, paediatric dentists and other health care professionals
required to cultivate and support positive attitudes among
parents. Preventive programs in preschools are required to
generate awareness among the parents of preventive oral
health care, oral hygiene habits, diet and feeding practices
and to promote early preventive visits of preschool children.
Barriers to attending oral healthcare such as the fear factor
of parents, various myths such as cultural beliefs associated
with dental treatment and role of an extended family system
PUULNH[P]LS`PUÅ\LUJPUN[OLWHYLU[»ZKLJPZPVUYLNHYKPUNVYHS
care, could be minimised by emphasising the importance of
VYHS OLHS[O HUK WYV]PZPVU VM HJJLZZPISL HUK HɈVYKHISL VYHS
health services at the primary level.
Acknowledgements
The research protocol of the study was reviewed and ethical clearance to
conduct the study was obtained from the Krishna College institutional review
board. The participants signed written consent forms before being interviewed.
References
Adair PM, Pine CM, Burnside G et al. Familial and cultural perceptions and
beliefs of oral hygiene and dietary practices among ethnically and socio-
economical diverse groups. Community Dent Health 2004; 21:102–111.
American Academy of Pediatric Dentistry. Clinical guidelines on infant oral
health care. 2011 http://www.aapd.org/media/Policies_Guidelines/G_
Infant OralHealthCare.pdf.
Blinkhorn AS. Dental preventive advice for pregnant and nursing mothers –
sociological implications. Int Dent J 1981; 31:14–22.
Davies GM, Worthington HV, Ellwood RP et al. A randomized controlled trial
VM[OLLɈLJ[P]LULZZVMWYV]PKPUNMYLLÅ\VYPKL[VV[OWHZ[LMYVT[OLHNLVM
12 months on reducing caries in 5–6 year old children. Community Dent
Health 2002; 19:131–136.
Davies MJ, Spencer AJ, Slade GD. Trends in dental caries experience of school
children in Australia – 1977 to 1993. Aust Dent J 1997; 42:389–394.
Finlayson TL, Siefert K, Ismail AI et al. Reliability and validity of brief measures
VMVYHSOLHS[OYLSH[LKRUV^SLKNLMH[HSPZTHUKZLSMLɉJHJ`PUTV[OLYZVM
African American children. Pediatr Dent 2005; 27:422–428.
Green W, Kreuter M. Health promotion planning: an educational and ecologi-
JHSHWWYVHJOYKLKU4V\U[HPU=PL^*(!4H`ÄLSK7\I*V 
Grewal N, Kaur M. Status of oral health awareness in Indian children as com-
pared to Western children: A thought provoking situation. J Indian Soc
Pedo Prev Dent 2007; 25:15-19.
Habibian M, Roberts G, Lawson M et al. Dietary habits and dental health
V]LY [OL ÄYZ[  TVU[OZ VM SPML *VTT\UP[` +LU[ 6YHS ,WPKLTPVS "
29:239–246.
Hallonsten AL, Wendt LK, Mejare I et al. Dental caries and prolonged breast-
feeding in 18-month-old Swedish children. Int J Paediatr Dent 1995;
5:149–155.
Harrison R, White L. A community-based approach to infant and child oral
health promotion in a British Columbia First Nations community. Can J
Community Dent 1997; 12:7-14.
Harrison RL, Wong T. An oral health promotion program for an urban minority
population of preschool children. Community Dent Oral Epidemiol 2003;
31:392–399.
Hilton IV, Stephen S, Barker JC et al. Cultural factors and children’s oral health
care: a qualitative study of carers of young children. Community Dent
Oral Epidemiol 2007; 35:429–438.
Holm AK. Caries in the preschool child: International trends. J Dent 1990;
18:291-295.
Lin HC, Wong MC, Wang ZJ et al. Oral health knowledge, attitude and prac-
tices of Chinese adults. J Dent Res 2001; 80:1466-1470.
4H[[PSH439H\[H]H7:PSSHUWHH4L[HS*HYPLZPUÄ]L`LHYVSKJOPSKYLUHUK
associations with family related factors. J Dent Res 2000; 79:875–881.
European Archives of Paediatric Dentistry 81
 N. Chhabra, A. Chhabra
Milgrom P, Fiset L, Melnick S et al. The prevalence and practice management
consequences of dental fear in a major US city. J Am Dent Assoc 1988;
116:641–647.
Mohebbi SZ, Virtanen JI, Murtomaa H et al. Mothers as facilitators of oral
hygiene in early childhood. Int J Pediatric Dent. 2008; 18:48-55.
Newbrun E. Preventing Dental Caries: Breaking the chain of transmission. J
Am Dent Assoc 1992; 123:55-59.
6RHKH 4 2H^HT\YH 4 2HPOHYH @ L[ HS 0UÅ\LUJL VM WHYLU[Z» VYHS OLHS[O
behaviour on oral health status of their school children: an exploratory
study employing a causal modelling technique. Int J Paediatr Dent 2002;
12:101–108.
Peterson PE, Aleksejuniene J, Christensen LB et al. Oral health behavior and
attitudes of adults in Lithuania. Acta Odontol Scand 2000; 58:243-248.
Pine CM, Adair PM, Nicoll AD et al. International comparisons of health
inequalities in childhood dental caries. Community Dent Health 2004;
21:121–130.
Riedy CA, Weinstein P, Milgrom P. An ethnographic study for understand-
ing children’s oral health in a multi-cultural community. Int Dent J 2001;
51:305–312.
82 European Archives of Paediatric Dentistry 13 (Issue 2). 2012
Sakai VT, Oliveira TM, Silva TC et al. Knowledge and attitude of parents or
caretakers regarding transmissibility of caries disease. J Appl Oral Sci
2008; 16:150-154.
:JOYV[O91)YV[O^LSS+14VɈH[[4,2*HYLNP]LYRUV^SLKNLHUKH[[P[\KLZVM
preschool oral health and early childhood caries (ECC). Int J Circumpolar
Health 2007; 66:153-167.
Stenberg P, Hakansson J, Akerman S. Attitudes to dental health and care
among 20 to 25-year-old Swedes: results from a questionnaire. Acta
Odontol Scand 2000; 58:102-106.
Suresh BS, Ravishankar TL, Chaitra TR et al. Mother's knowledge about pre-
school child's oral health. J Indian Soc Pedo Prev Dent 2010; 28:282-287.
Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their
`V\UNJOPSKYLU!VUL`LHYÄUKPUNZ1(T+LU[(ZZVJ"!
Winter GB. Caries in the preschool child. J Dent 1990; 18:325-326.
Wong D, Spiess SP, Julliard K. Attitudes of chinese parents toward the oral
health of their children with caries: A qualitative study. Pediatric Dentistry
2005; 27:505-512.