Submitted: 06 June, 2023 Accepted: 14 July, 2023 Published: 03 January, 2024 DOI:10.22514/jocpd.2024.

017

ORIGINAL RESEARCH

Oral health related knowledge, attitude and behavior

among group of mothers in relation to their primary
school children's oral health: a cross-sectional study
Nada O. Bamashmous1 , Eman A. El Ashiry1 , Najlaa M. Alamoudi1 , Dhuha K Qahtan2 ,
Rana A. Alamoudi1 , Osama M. Felemban1, *

1
Department of Pediatric Dentistry, Abstract
Faculty of Dentistry, King Abdulaziz
University, 21589 Jeddah, Saudi Arabia
The etiology of oral diseases in children is complex and multifactorial. The oral health
2
Private practitioner of pediatric of children can be influenced by various factors, including parental knowledge, attitudes
dentistry, 23719 Jeddah, Saudi Arabia and behaviors, as well as socioeconomic status. The objective of this study was to
assess, among mothers of children aged 6–12 years, (1) mothers’ knowledge about
*Correspondence
[email protected]
their children’s oral health, (2) mothers’ attitude toward their children’s oral health,
(Osama M. Felemban) and (3) mothers’ dental behavior concerning their oral health and to evaluate their
influence on their children’s dental caries. This cross-sectional study involved three
questionnaires to be filled in by mothers of primary school children in addition to an oral
examination of their children to measure decayed, missing, filled teeth for primary (dmft)
and permanenet (DMFT) dentitions. The mother-child pairs were recruited through
multistage stratified random sampling of primary schools in Jeddah, Saudi Arabia.
The questionnaire was comprised of four sections: 1—demographic characteristics and
socioeconomic status 2—Hiroshima University Dental Behavioral Inventory (mothers’
attitudes and behavior pertaining to their oral health) 3—mothers’ knowledge regarding
the oral health of their children 4—mothers’ attitude toward their children oral health. A
total of 1496 mother-child pairs completed the study. The mean values of dmft were 4.08
± 3.47; DMFT was 1.82 ± 2.07; total dmft and DMFT were 5.65 ± 4.05. According to
the questionnaire results, mothers in private schools had a more favorable attitude and
behavior toward their oral health, as well as a more favorable knowledge and attitude
toward their children’s oral health. The multiple linear regression model revealed that
children’s dmft/DMFT scores were significantly related to mother education, mother
questionnaire scores, and the Simplified Oral Hygiene Index. Children’s oral health is
significantly impacted by oral health-related knowledge, attitude and behaviors of their
mothers in addition to income status and education level.

Keywords
Oral health; Mothers; Children; Knowledge; Attitude; Behavior; Primary schools;
Dental caries; Oral hygiene index

1. Introduction as manageable. But public health initiatives are impeded by a

lack of knowledge of related variables in vulnerable groups [3].
Oral health is an essential part of overall health and well-being, Children in Arab nations experience significant rates of dental
with growing data suggesting an association between oral and caries, both in terms of prevalence and severity. In the Arabian
systemic health for serious disorders including cancer, mild Gulf Countries, the overall mean number of permanent teeth
cognitive impairment, arthritis, diabetes and cardiovascular that are decayed, missing or filled is 2.57, while the prevalence
disease [1]. Even though oral health has made enormous of dental caries is 64.7% of 6–16 years of age children [4].
strides, the burden of oral health disorders is still quite high In Saudi Arabia, the prevalence of dental caries remained
globally. This may be primarily due to a lack of healthy oral high reaching 84% as recently reported [5]. Dental caries is
behaviors that are essential in managing the most prevalent oral quite common in nations where preventive strategies for oral
diseases, such as dental caries and periodontal disease, with diseases have not yet been put into place. In research on the
a prevalence rate of up to 47.6% or more in school children prevalence of dental caries in school children, aged 12 to 14
around the globe [2]. years in Riyadh, it was found that just 6.3% of the entire sample
was caries-free, with an estimated 93.7% caries frequency
Dental caries is a childhood illness that is preventable as well

This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

J Clin Pediatr Dent. 2024 vol.48(1), 152-162 ©2024 The Author(s). Published by MRE Press. www.jocpd.com
 153

[6]. According to another study carried out in Saudi Arabia, children.

school children had inadequate periodontal health knowledge
and behavior [7]. Saudi students’ oral health knowledge, 2.2 Sampling methodology
attitudes and behavior are still little understood. Therefore, the
A multistage stratified random sampling technique was
Saudi community as well as international organizations like
adopted to select the participants from primary schools in each
the World Health Organization (WHO) and health authorities
district from Jeddah City, Saudi Arabia. For stratification
would benefit from knowing the related causes for dental caries
purposes, three criteria were undertaken:
in Saudi children. This will help them focus their mitigation
efforts on susceptible groups like children. • District-wise (west, east, north, south), resulting in four
strata.
The association between parents and their children’s oral
• Each district strata were divided into public or private,
health has been investigated since 1946 with a stronger as-
producing 8 strata.
sociation among mothers than fathers [8]. Parents are the
primary regulators of their children’s nutritional intake [9]. • Finally, each of the 8 strata was stratified by gender into
The lack of parental knowledge and inconsistency between boys and girls, resulting in 16 strata.
the parent’s dental knowledge and their actual practice were Schools in each of the 16 strata were listed and numbered
reported as major risk factors for dental caries [10]. Adherence and one school from each stratum was selected using a software
to healthy oral habits, such as twice-daily teeth brushing with (random number generator) resulting in 16 primary schools. A
fluoride toothpaste and minimizing intake of sugary foods sample size of the children was calculated based on previous
and beverages, is essential for the prevention of childhood research [18]. A two-sided 95% confidence interval for a
dental caries [11]. The reality is that understanding these single proportion using the large sample normal approximation
signals by children on their own seldom results in long-lasting modified for a finite population of size 300,000 will stretch
behavioral change in people. Simple oral hygiene practices 3% from the observed percentage for an expected proportion
are intertwined with more complicated daily routines, which of 50% when the sample size is 1529. A slightly greater
are significantly influenced by a wide range of psychological, number of questionnaires (1728) were to be distributed to
environmental and economic factors [12]. Hence, mothers’ compensate for any dropout of study participants, incomplete
knowledge, attitude and behavior toward oral health need to be questionnaires or the child’s absence/resistance to the oral
optimum to maintain their own and their children’s oral health. examination. Six classes were chosen from each school, one
from each grade. The bowl technique was employed for the
Another important risk factor that might affect dental caries
random selection of each class, in which class numbers were
among children is the socioeconomic status of the family. The
written on paper slips, placed in a bowl and then blindly drawn
association between dental caries and socioeconomic status is
out. From each of the six classes, 18 children from each class
well-established [13]. Children of fathers with higher socioe-
were randomly selected by the class instructor, along with their
conomic status and non-working mothers were found to have
mothers. In the case of a small number of children in the school
lower caries prevalence compared to those with lower socioe-
(less than 108), all children in the school were included in the
conomic status [14, 15]. Previous studies reported a higher
sample.
prevalence of poor oral health in children of mothers with
low educational levels [16]. Additionally, it was reported that
mothers with lower educational levels had poorer knowledge 2.3 Inclusion and exclusion criteria
regarding their children’s oral health leading to an increased This survey included mother-child pairs. The inclusion criteria
incidence of early childhood caries [17]. Although the majority of the children were: Saudi children (aged 6–12 years) with
of Saudi children suffer from oral disorders, notably dental good general health, according to the American Society of
caries, little is known about the extent and variables influenc- Anesthesiologists (ASA) classification [19]. The included
ing dental caries, oral hygiene habits and behavior throughout mothers had to be Saudi nationals and capable of filling out
most of the nation, particularly in the study location of Jeddah self-administered questionnaires. Children who resisted oral
city. The purpose of this study was to gather baseline data on examination and incomplete questionnaire responses were ex-
the mother’s knowledge, attitude and behavior of their primary cluded.
school children, aged 6 to 12 years, concerning oral health, and
to assess its influence on the oral health status of their children 2.4 Questionnaire design
in terms of dental caries experience.
An Arabic self-administered questionnaire, comprising four
2. Materials and methods sections and a total of 49 questions, was used for this study
to be completed by mothers. The questionnaire had a cover
letter describing the aim of the study and the informed consent
2.1 Study population
was attached to this section. Section I was structured to record
The primary schools in Jeddah, Saudi Arabia consist of a the demographic characteristics like child gender, mothers’
total of 737 schools (public and private), segregated by gen- age (40 years or less, 41 years or more), educational level
der into 344 male and 393 female schools, according to the (High school or less Diploma/University), and monthly family
country’s regulations. The registered number of male and income (low, medium or high). Section II employed the
female students in the academic year 2017–2018 were 147,525 Hiroshima University-Dental Behavioral Inventory (HU-DBI)
and 145,848, respectively, accounting for a total of 293,373 questionnaire which consisted of 20 items to evaluate the
154

attitudes and behaviors of mothers pertaining to their oral artificial lighting.

health [20]. A score was calculated based on the sum of The oral hygiene status of the children was assessed using
agree/disagree responses by giving one point to each favorable the Debris Index component (DI) of the Greene and Vermillion
response of good oral health. High scores indicate good oral Simplified Oral Hygiene Index (OHI-S) [25]. A brief report
health attitudes and behaviors. Section III was a questionnaire was sent to the mothers describing the oral health status of their
adapted from Prabhu et al. [21] to evaluate mothers’ knowl- children and instructions for improvement and/or maintaining
edge about their children’s oral health. The questionnaire the oral health condition. The examination was conducted
consisted of 12 questions which mothers selected the best by four examiners (two male examiners for the boys’ schools
response from multiple choices. To calculate a score, one point and two female examiners for the girls’ schools). Before the
was given for each correct answer. Section IV, a questionnaire commencement of the study, the four examiners were trained
adopted from Lenčova et al. [22], was used to assess the and calibrated for dental caries and oral hygiene assessment.
mothers’ attitudes toward their children’s oral health. It was Inter and intra-rater reliability tests were done for calibration
composed of 13 agree/disagree questions where one point was and training of the examiners. Kappa statistic was calculated
given for each correct answer to calculate a total score. and found excellent (0.93 for female and 0.95 for male ex-
aminers). The inter-rater reliability between the examiners
2.5 Translation and validation was evaluated using the Intra-class Correlation (ICC) and was
Arabic Translation of the questionnaires was carried out by two found to be 0.96. On the third school visit, mother-child pairs
certified linguists. Forward and back-translation were used. were gathered in the school for an oral health education lecture
The first linguist, who is fluent in both Arabic and English and distribution of oral health instruction pamphlets to increase
languages, translated the questionnaire from English to Arabic. their awareness of the proper oral health knowledge, attitude
The other linguist translated back the Arabic version into the and behavior regarding themselves and their children.
English language. Then, a dental public health professor
who was also fluent in Arabic and English compared the two 2.7 Statistical analysis
English questionnaires (the original one and translated one)
Data was entered, coded and analyzed using the Statistical
and made modifications after discussion with the two linguists
Package for Social Science SPSS (IBM Statistics for Windows,
until the final Arabic-translated version was formulated.
Version 23.0 Armonk NY, USA: IBM Corp). The responses to
Test-retest Reliability of the Arabic questionnaire was done.
the three questionnaires from public schools were compared
The final Arabic version of the questionnaire was completed
to private schools using a chi-square test. The association
twice with two weeks intervals by a group of mothers (n = 30)
between the demographic variables and questionnaire score,
not included in the study. The results were compared using
DMFT and OHI-S was evaluated using an independent t-test
Pearson’s correlation coefficient (Pearson’s r) as a reliability
or Analysis of Variance (ANOVA) test which was followed by
test and was found to equal 0.90 which was considered excel-
post hoc analysis. Multiple linear regression was modeled to
lent. Moreover, internal consistency was done to reflect the
assess the effects of all the significant independent variables on
inter-correlation between items in the questionnaire and was
the DMFT (dependent variable). The significance level was set
quantified using Cronbach’s alpha to be 0.86.
as p < 0.05.
Content validity of the Arabic-translated version of the ques-
tionnaire was performed to recognize if the questionnaire items
were representative of the entire theoretical construct that the 3. Results
questionnaire was proposed to measure. A panel of experts
in pediatric dentistry were asked to rate each item in the 3.1 Descriptive statistics
questionnaire concerning relevance, clarity, simplicity and The research comprised a total of 1496 mother-child pairs
ambiguity on a four-point Likert scale. The Content Validity out of the 1728 distributed questionnaires (a response rate of
Index (CVI) was calculated according to the methodology of 86.57%). A little over half were from private schools (50.2%).
Lynn [23] and was found to be 0.84. About half (53.8%) of the children were aged 6–9 years and
46.2% were aged 10–12 years. Male children accounted for
2.6 Data collection 47.1% and female children for 52.9%. Mothers’ age has been
The schools were visited thrice. The purpose of the first visit distributed according to the following figures: 56.2% were
was to distribute the questionnaire to the selected children in aged 40 years or less and 43.8% were aged 41 years or older.
the class to take home to their mothers. Each questionnaire Only 44.3% of mothers had a high school education or less
was assigned a serial number which was matched with an whilst 55.7% had a diploma or university education. Less than
examination sheet for confidentiality purposes. The second a quarter of mothers had a low monthly income (22.4%), less
visit was carried out after one week, for the collection of the than half had a medium-income (46.7%), and less than one-
questionnaires and clinical oral examination for the children third had a high income (30.9%). Table 1 shows the demo-
who had permission from their mothers to assess dental caries graphic characteristics of children and mothers. Concerning
experience using dmft and DMFT indices [24]. Oral health the children’s oral health, the average dmft was 4.08 ± 3.47;
examination as undertaken in the school classroom. The re- DMFT was 1.82 ± 2.07; total dmft and DMFT was 5.65 ±
search examiners used sets of sterile instruments (community 4.05; and the Debris Index was 1.17 ± 0.94.
periodontal index (CPI) probe and mirrors) in addition to
 155

TA B L E 1. Demographic features of the research sample 3.4 Mothers' attitude toward child's oral
children and their mothers. health
Variable Category Frequency (%) Table 4 shows disparities in the replies between public and
School type private school mothers on the mother’s attitude questionnaire.
Public 745 (49.8) Of the 13 assertions, replies to 4 statements (3, 5, 11 and 12)
out of the 13 statements showed no statistically significant
Private 751 (50.2)
difference between mothers in public and private schools. In
Child age their replies to the 9 reminiscent statements (1, 2, 4, 6, 7, 8,
6–9 yr 805 (53.8) 9, 10 and 13), the attitude of mothers at private schools was
10–12 yr 691 (46.2) significantly higher than that of mothers at public schools.
Child gender
3.5 Factors affecting oral health in public
Male 704 (47.1)
and private schools
Female 792 (52.9)
Table 5 shows the relationships between dmft/DMFT and chil-
Mother’s age
dren’s and mothers’ demographics, as well as questionnaire
40 or less 841 (56.2) scores in public and private schools. Children of younger
41 or more 655 (43.8) mothers (40 years or less) had substantially higher mean dmft
Mother’s education scores (6.0 ± 4.0) than children of mothers 41 years or older
(4.5 ± 4.1) in public schools (p < 0.001). The mean DMFT
High school or less 663 (44.3)
of private school children of younger mothers (3.8 ± 3.4) was
Diploma/University 833 (55.7) substantially lower than that of children of older mothers (5.9
Monthly Income ± 3.9) (p < 0.001). Furthermore, dmft and DMFT mean scores
Low 335 (22.4) in both public and private schools were significantly higher
among children of mothers with a high school education or
Medium 698 (46.7)
less compared to mothers with university education; children
High 463 (30.9) of families with lower monthly incomes compared to higher
incomes; children of mothers with lower questionnaire scores
compared to higher scores; and children with poor or fair oral
3.2 Attitude and behavioral practices of hygiene compared to children with good oral hygiene.
participating mothers Two multiple linear regression models (adjusted) were used
to quantify the impacts of the questionnaire scores on the
The replies of the mothers to the HU-DBI questionnaire are dmft/DMFT index (dependent variable) controlling for con-
shown in Table 2. When comparing mothers of children in founding (Table 6). Overall, 39.0% and 44.7% of the data
public vs. private schools, there was a statistically significant variability was accounted for by the dmft/DMFT model in
difference in 16 out of the 20 questions. Regarding replies to public and private schools, respectively. Children of mothers
questions 6, 8, 9 and 16, the differences were not statistically with lower HU-DBI questionnaire had higher dmft/DMFT on
significant between mothers who enrolled their children in average by 1.7 (95% confidence interval (CI), 1.1–2.3) in
public schools vs. those in private schools. Mothers in public public schools and 1.3 (95% CI, 0.8–1.9) in private schools
schools had much higher favorable replies to questions 3, 4 and controlling for confounders. Children of mothers in public
13 compared to mothers in private schools. Mothers at private schools with lower scores in attitude towards their children’s
schools tended to provide more favorable replies to questions oral health had significantly higher dmft/DMFT by 1.2 (95%
1, 2, 5, 7, 10, 11, 12, 14, 15, 17, 18, 19 and 20. CI, 0.7–1.8) after controlling for confounding.

4. Discussion
3.3 Mothers' knowledge regarding child
oral hygiene This descriptive survey gave a detailed explanation of various
influences on the oral health practices of children (aged 6–12
years) from the viewpoint of their mothers in Jeddah, Saudi
In Table 3, public and private school mothers held different Arabia. This survey employed an acceptable sample size,
views on oral health and good oral hygiene. When it comes chosen at random from both genders of primary school (public
to mothers’ awareness of oral health and oral hygiene habits, and private) students who are in a period of developing their
mothers of children in private schools had better results com- health habits [12], in contrast to prior interventions targeting
pared to mothers of children in public schools. However, when newborns [26] and preschool children [27], whose oral health
questioned about the optimum quantity of toothpaste to be is mostly taken care of by their parents. To our knowledge,
used and about their position when brushing their children’s this is the first study implemented to examine both mothers’
teeth, the replies of mothers in public schools were superior to perceptions of the factors that influence their children’s im-
mothers in private schools. portant oral health habits as well as their opinions regarding
oral health support. Prior descriptive research done in Saudi
156

TA B L E 2. Comparison between public and private schools of mothers’ answers to the Hiroshima University-Dental
Behavioral Inventory (HU-DBI)-questionnaire.
Public Private
Items The correct answer n = 745 n = 751 p-value
n (%) n (%)
1 I don’t worry much about visiting the Agree 246 (33.0) 385 (51.3) <0.001
dentist

2 My gums tend to bleed when I brush my Disagree 495 (66.4) 601 (80.0) <0.001
teeth

3 I worry about the color of my teeth Agree 554 (74.4) 379 (50.5) <0.001

4 I have noticed some white sticky deposits Agree 82 (11.0) 31 (4.1) <0.001
on my teeth

5 I use a recommended-sized toothbrush Agree 690 (92.6) 745 (99.2) <0.001

6 I think that I cannot help having false teeth Disagree 48 (6.4) 32 (4.3) 0.061
when I am old

7 I am bothered by the color of my gums Disagree 602 (80.8) 673 (89.6) <0.001

8 I think my teeth are getting worse despite Disagree 441 (59.2) 426 (56.7) 0.333
my daily brushing

9 I brush each of my teeth carefully Agree 630 (84.6) 653 (87.0) 0.186

10 I have never been professionally taught Disagree 169 (22.7) 297 (39.5) <0.001
how to brush

11 I think I can clean my teeth without using Agree 125 (16.8) 223 (29.7) <0.001
toothpaste

12 I often check my teeth in a mirror after Agree 494 (66.3) 598 (79.6) <0.001
brushing

13 I worry about having bad breath Agree 166 (22.3) 84 (11.2) <0.001

14 It is impossible to prevent gum disease Disagree 214 (28.7) 309 (41.1) <0.001
without toothbrushing alone

15 I put off going to the dentist until I have a Disagree 63 (8.5) 148 (19.7) <0.001
toothache

16 I have used a dye to see how clean my teeth Agree 22 (3.0) 18 (2.4) 0.505
are

17 I use a toothbrush that has hard bristles Disagree 573 (76.9) 670 (89.2) <0.001

18 I don’t feel I’ve brushed well unless I brush Disagree 370 (49.7) 463 (61.7) <0.001
with strong strokes

19 I feel I sometimes take too much time to Agree 358 (48.1) 545 (72.6) <0.001
brush my teeth

20 I have had my dentist tell me that I brush Agree 127 (17.0) 276 (36.8) <0.001
very well

p-value < 0.05 significant difference.

 157

TA B L E 3. The comparison between public and private school mothers’ answers to the questionnaire of mothers’
knowledge about their children’s oral health.
Public Private
Items The correct answer p-value
n = 745 n = 751
1 How often should you brush your child’s teeth Twice daily 350 (47.0) 434 (57.8) <0.001
2 Size of brush best for your child Small 398 (53.4) 430 (57.3) 0.136
3 Quantity of paste to be used Pea size 362 (48.6) 225 (30.0) <0.001
4 Your position to brush your child’s teeth By the side of the 418 (56.1) 299 (39.8) <0.001
child
5 Does your child’s toothpaste have fluoride Yes 460 (61.7) 639 (85.1) <0.001
6 The fluoride content of child paste 1000 to 1450 ppm 59 (7.9) 151 (20.1) <0.001
Four of the following cause tooth decay.
○ Chocolate ○ Chocolate
○ Cheese ○ Biscuits
7 651 (87.4) 686 (91.3) 0.013
○ Biscuits ○ Sweets
○ Sweets ○ Soft drink
○ Soft drink
8 Best time to give sugary snacks Mealtime 64 (8.6) 121 (16.1) <0.001
9 Has the child used a sweetened baby bottle or honey- No 540 (72.5) 609 (81.1) <0.001
dipped pacifier
10 Importance of decay in baby teeth Very important 667 (89.5) 738 (98.3) <0.001
11 Child’s first dental visit On getting the first 50 (6.7) 80 (10.7) 0.007
baby tooth
12 If baby teeth decayed, what treatment would you prefer Fill it 545 (73.2) 682 (90.8) <0.001
p-value < 0.05 significant difference.

TA B L E 4. Comparison between public and private schools of the answers from the mothers’ attitudes towards their
children’s oral health questionnaire.
Public Private
Items The correct answer p-value
n = 745 n = 751
1 We feel it is important that we check our child’s teeth for Agree 732 (98.3) 750 (99.9) 0.001
decay
2 I don’t know how to brush my child’s teeth properly Disagree 358 (48.1) 499 (66.4) <0.001
3 We feel it is important to check if our child has brushed Agree 717 (96.2) 727 (96.8) 0.552
his/her teeth
4 We don’t have time to help brush our child’s teeth daily Disagree 247 (63.4) 537 (71.5) 0.001
5 It is the responsibility of the dentist to prevent our child Disagree 220 (29.5) 252 (33.6) 0.094
from getting tooth decay
6 If our child gets tooth decay, it is by chance Disagree 412 (55.3) 584 (77.8) <0.001
7 It would not make any difference to our child getting tooth Disagree 169 (22.7) 265 (35.3) <0.001
decay if we helped him/her brush every day
8 It is worthwhile to give our child sweets/biscuits to Disagree 312 (41.9) 463 (61.7) <0.001
behave well
9 Tooth decay is a serious problem in baby teeth Agree 406 (54.5) 540 (71.9) <0.001
10 As parents, it is our responsibility to prevent our child Agree 648 (87.0) 700 (93.2) <0.001
getting tooth decay
11 We can prevent tooth decay in our child by reducing Agree 732 (98.3) 732 (97.6) 0.374
sugary foods and drinks between meals
12 If we brush our child’s teeth daily, we can prevent our Agree 537 (72.1) 570 (75.9) 0.092
child from getting tooth decay in the future
13 If our child uses fluoride toothpaste, it will prevent tooth Agree 623 (83.6) 701 (93.5) <0.001
decay
p-value < 0.05 significant difference.
158

TA B L E 5. Associations between the demographics and questionnaire scores and the dmft and DMFT scores in public
and private schools.
Public schools Private schools

dmft/DMFT p-value dmft/DMFT p-value

Child gender

Male 7.0 ± 4.2 4.4 ± 3.2

0.031 0.219
Female 6.4 ± 4.0 4.8 ± 4.1

Mother’s age

40 years or less 6.0 ± 4.0 3.8 ± 3.4

<0.001 <0.001
41 years or more 4.5 ± 4.1 5.9 ± 3.9

Mother’s education

High school or less 8.0 ± 3.8 7.2 ± 3.4

<0.001 <0.001
Diploma/University 4.4 ± 3.6 3.8 ± 3.5

Monthly income

Low 8.8 ± 3.5 a 0

Medium 5.1 ± 3.7 b <0.001 6.5 ± 3.6 <0.001

High 4.0 ± 4.1 b 3.2 ± 3.2

Questionnaire 1 score

Low 8.1 ± 3.7 7.2 ± 3.6

<0.001 <0.001
High 3.9 ± 3.3 3.2 ± 3.0

Questionnaire 2 score

Low 7.8 ± 3.8 6.3 ± 3.8

<0.001 <0.001
High 4.6 ± 3.7 3.6 ± 3.4

Questionnaire 3 score

Low 7.9 ± 3.8 6.3 ± 3.4

<0.001 <0.001
High 4.4 ± 3.5 3.3 ± 3.5

Debris index

Poor 8.4 ± 3.5 a 7.4 ± 3.3 a

Fair 6.1 ± 3.5 b <0.001 5.1 ± 3.1 b <0.001

Good 4.1 ± 4.0 c 2.3 ± 2.8 c

dmft: decayed, missing, filled primary teeth; DMFT: decayed, missing, filled permanent teeth. Means sharing the same
alphabetical letter are not statistically different form each other at p < 0.05 using post hoc pairwise comparisons. Means that
have different alphabetical letters are statistically different from each other at p < 0.05 using post hoc pairwise comparisons.
Questionnaire 1: Hiroshima University-Dental Behavioral Inventory (HU-DBI)-questionnaire to evaluate attitudes and behaviors
of mothers pertaining to their oral health. Questionnaire 2: Mothers’ knowledge about their children’s oral health. Questionnaire
3: Mothers’ attitudes towards their children’s oral health. p-value < 0.05 significant difference.
 159

TA B L E 6. Model of the impacts of different variables on dmft and DMFT (multiple linear regression).
Independent variables Public schools Private schools
(R2 = 0.390) (R2 = 0.447)
β ± SE (95% CI) p-value β ± SE (95% CI) p-value
Mother’s age
40 years or less 0.1 ± 0.3 (−0.4–0.6) 0.561 −0.4 ± 0.2 (−0.8–0.1) 0.098
41 years or more Reference Reference
Mother’s education
High school or less 1.0 ± 0.3 (0.4–1.6) 0.002 0.4 ± 0.3 (−0.2–0.9) 0.241
Diploma/University Reference Reference
Monthly income
Low 1.1 ± 0.7 (−0.3–2.4) 0.114 NA
Medium −0.5 ± 0.6 (−1.7–0.7) 0.412 1.2 ± 0.3 (0.7–1.7) <0.001
High Reference Reference
Questionnaire 1 score
Low 1.7 ± 0.3 (1.1–2.3) <0.001 1.3 ± 0.3 (0.8–1.9) <0.001
High Reference Reference
Questionnaire 2 score
Low 0.5 ± 0.3 (−0.1–1.1) 0.089 0.3 ± 0.3 (−0.2–0.8) 0.308
High Reference Reference
Questionnaire 3 score
Low 1.2 ± 0.3 (0.7–1.8) <0.001 0.4 ± 0.3 (−0.1–0.9) 0.124
High Reference Reference
Debris index
Poor 1.8 ± 0.3 (1.1–2.4) <0.001 3.3 ± 0.3 (2.8–3.9) <0.001
Fair 1.0 ± 0.3 (0.3–1.7) 0.005 2.2 ± 0.3 (1.6–2.7) <0.001
Good Reference Reference
SE standard error; CI confidence interval. Questionnaire 1: Hiroshima University-Dental Behavioral Inventory (HU-DBI)-
questionnaire to evaluate attitudes and behaviors of mothers pertaining to their oral health. Questionnaire 2: Mothers’ knowledge
about their children’s oral health. Questionnaire 3: Mothers’ attitudes towards their children’s oral health. p-value < 0.05
significant difference.

Arabia focused on the dental literature that had a narrow oral hygiene practices based on age and educational attain-
focus on tooth-brushing behavior [28]. This study has the ment. Studies carried out in Kuwait and Spain revealed a
advantage that this data permits a comprehensive and elaborate link between greater knowledge and improved dental health
examination of the indirect procedures involved in the behav- [30, 31]. Good oral hygiene habits can be developed primarily
ioral adoption, whereas quantitative data is sometimes limited through self-inflicted behaviors such as maintaining dental hy-
to investigating direct correlations between measurable and giene, restricting one’s diet, especially reducing consumption
predetermined factors. A qualitative study that examines par- of sugary foods and beverages, using fluoridated products, and
ents’ opinions on the impacts of childhood dental caries might also with the aid of dental services that are readily available,
help us better understand the factors that contribute to tooth such as scheduling routine dental checkups, using primary and
decay in children. It is crucial to record their opinions since preventive care, and receiving dental health education [10].
families have a significant influence in developing children’s
The findings of this survey revealed that mothers whose
oral hygiene practices and also because parents are the primary
children attend private primary schools have higher significant
regulators of their children’s nutritional intake. Additionally,
questionnaire scores on average (Oral health behavior; HU-
parents might express their thoughts on the coaching required
DBI, knowledge and attitude) as compared to mothers of public
to enhance these oral hygiene practices. When creating strate-
primary school children. The study’s findings can be ascribed
gies to prevent dental caries, both factors are crucial to take
to the fact that private schools provide the healthiest environ-
into account [29].
ments and are linked to decreased risks of oral diseases because
Literature reports that oral health knowledge and awareness they are small, safe and have superior teacher monitoring of
are extremely low and that there are significant disparities in students, high resources, parental involvement and community
160

activities. As opposed to public schools, many private schools education and/or income. These results could be explained by
in Jeddah encourage children to brush their teeth after breakfast the fact that mothers have a significant role in their children’s
and stay away from sugary food. Children who attend private dental health and that their high levels of education enable
schools also have better status of monthly incomes and more them to seek out the best oral hygiene practices. Mothers
educated parents than children who attend public schools. Due with a higher level of education can use the internet, social
to the easy availability of sugary meals, children at public media and electronic periodicals to find reliable oral health
schools are more prone to develop dental caries. Additionally, information thus they are likely to be more aware of the
the lack of oral health education in public schools and the risks of neglecting oral health and the oral disorders that may
financial struggles of the families of these students are the main harm their children. Higher-educated mothers recognize the
barriers to the prevention of dental caries in students attending necessity of teaching their children how to brush their teeth
public schools. Thus, the school environment matters for and examine them thereafter. This may motivate children to
student outcomes and affects their health and well-being [32]. brush their teeth thoroughly and maintain good oral hygiene.
Furthermore, these arguments are supported by a study done by Another possibility is that children of mothers with higher
Al Saffan in 2017 conducted in Riyadh, which indicated that levels of education and income have more frequent dental
oral health educational sessions in private schools improved checkups. In the current study, most highly educated mothers
schoolchildren’s oral health awareness [33]. In contrast to our and those with higher levels of income took their infants to the
findings, an Indian study found that the majority of mothers dentist when they were six to twelve months old, whereas the
of children in private schools had a mediocre understanding majority of illiterate parents took their children to the dentist
of oral health [34]. In addition, an Iranian study indicated that only when they were in pain. This practice can be ascribed
mothers of children in public schools had a good understanding to the absence of suitable oral health education initiatives,
and attitude toward dental health [35]. However, neither study which may have rendered dental care redundant. According
revealed the participants’ socioeconomic background, which to another study [44], children’s oral health is directly related
could have a substantial confounding effect on the relationship to their monthly family income, and children of low-income
between school type (private vs. public) and oral health-related mothers use fewer dental services than children of high-income
knowledge, attitudes and behavior. Interventions that concen- mothers. Also, our results are consistent with an Egyptian
trate on the school environment as opposed to just specific study that showed a statistically significant difference between
components may be successful in avoiding dental caries [36], mothers’ knowledge, socioeconomic status and education level
particularly in lowering socioeconomic disadvantages. on the dental caries status of their children [45]. Similarly,
The current study also brought to light a statistically signif- our findings are also in line with various studies conducted in
icant difference between children attending public and private different cities of Saudi Arabia that found a link between edu-
schools regarding their dmft/DMFT and DI mean scores. Chil- cational and financial levels, as well as oral hygiene knowledge
dren in private primary schools have lower dmft/DMFT and and attitudes [46–48]. However, some studies showed no link
DI mean scores on average than children in public primary between mothers’ education levels and the dmft scores of their
schools, according to our research. Children who attended children [49]. The key to a motivated and informed public lies
public schools had higher debris indices and caries severity in significant oral hygiene practices and knowledge.
ratings. Children that attend the same school are likely to The clinical implication of this study was to underline the
have a similar impact on these characteristics because they need for mothers’ and children’s oral health education to in-
have common contextual variables [37]. The results are in crease oral health awareness and implement school oral health
concordance with a 2021 study conducted among public and promotion programs in the primary care center and the social
private primary school students in Iran, which recorded that the media. Primary-level students serve as the ideal target group
mean dmft index in private school students was significantly to acquire initial organized intervention because, at this stage,
lower than that of public schools [38]. Similarly, a 2016 study the molding of behaviors is quite simple. This leads to accurate
in Nigeria, found that children in private schools scored lower knowledge as well as a positive attitude, which is essential to
on the DMFT than children in public schools [39]. In India, it modify their oral hygiene practices. Moreover, Oral health
was discovered in 2016 that children in private schools (12–13 awareness programs are to be adopted by the Ministry of
years old) had a lower DMFT mean score than kids in public Health and implemented in the primary school curriculum at
schools with a statistically significant difference [40]. Similar different school levels. Furthermore, oral health campaigns
results were reported from Karachi, Pakistan, with a statisti- should focus on public schools. However, if health initiatives
cally significant difference [41]. In Brazil in 2004, children in can’t directly influence attitudes and don’t take into account
public schools had higher dmft/DMFT than children in private numerous socioeconomic and environmental aspects of the tar-
schools, with a statistically significant difference [42]. On geted population, their effectiveness will be restricted. Thus,
the contrary, there was no statistically significant difference effective policies require to be drafted to minimize the burden
in dmft/DMFT scores between public and private school stu- of dental caries among children attending primary schools.
dents in Port Harcourt, Nigeria, despite private school students Since children’s oral health-related practices and behaviors
having lower dmft/DMFT scores [43]. are significantly impacted by oral health-related behaviors of
The present study revealed that mothers with higher educa- both parents, therefore, further investigation of the association
tion and/or income had significantly better oral health-related between the father’s income status and education level needs
knowledge, attitudes and behavior, and their children had to be conducted to shed a clearer light upon the results of this
fewer cavities and lower DI as compared to mothers with lesser survey and finally to get a comprehensive and elaborate view
 161

of the issue at hand. Arabia, under grant number G: 419.165.1440.

5. Conclusions
CONFLICT OF INTEREST
This survey provides background information to get an insight The authors declare no conflict of interest.
into the degree of oral health-related knowledge, attitude and
behavior among mothers of primary school children. The study
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