Assessing Mothers' Knowledge of Preventing Dental Caries in Breastfed versus Bottle-Fed Children: A Cross-Sectional StudyABSTRACT
Objective: To assess maternal knowledge about ECC prevention in breastfed versus bottle-fed children, exploring how breastfeeding practices and socio-demographic factors like education and income influence this understanding.
Material and Methods: This cross-sectional study involved 340 mothers from the dental clinics at Qassim University. Mothers, aged 20-49 and currently breastfeeding or bottle-feeding, completed questionnaires covering socio-demographic background, birth-related information, and knowledge about the dental health of toddlers. The questionnaires were adapted from previous studies and translated into Arabic. Data analysis was conducted using SPSS, focusing on descriptive statistics and Chi-square tests.
Results: The majority of participating mothers fell within the 30-39 age range, were employees, and predominantly practiced mixed feeding. While many showed acceptable to high knowledge about child dental prevention and awareness of dental caries due to lactation, significant gaps were noted in areas like the timing of the first dental visit and understanding of the impact of nocturnal breastfeeding on caries development. Variations in knowledge were also observed across different income groups and lactation types.
Conclusion: The study highlights the need for targeted educational interventions to bridge knowledge gaps among mothers, particularly regarding the timing of dental appointments and the implications of feeding practices on dental health. It underscores the importance of educational and socio-economic factors in shaping maternal knowledge about ECC prevention.
Keywords:
Epidemiologic Studies; Health Education; Dental; Knowledge.
Introduction
Breastfeeding is widely recognized as the ideal method for infant feeding, providing essential nutrients and promoting overall health and development. The World Health Organization (WHO) recommends exclusive breastfeeding during the first six months of life, followed by the introduction of complementary foods alongside continued breastfeeding until two years of age or beyond [1]. However, as infants transition to the intake of solid foods, concerns about the risk of dental caries arise.
Early Childhood Caries (ECC) is defined as the presence of decayed, missing, or filled surfaces in any primary tooth of a child under the age of 71 months [2]. According to the 2015 Global Burden of Diseases study, dental caries in primary dentition ranked as the 12th most prevalent condition across all age groups, affecting approximately 560 million children [3]. Recent literature reviews indicate that the global prevalence of caries in primary teeth is 46.2%, while it is 53.8% for permanent teeth, with lower estimates observed in European countries and higher estimates in African countries [4]. The WHO Global Oral Health Status Report (2022) estimates that oral diseases affect nearly 3.5 billion people worldwide, with three-quarters of those affected living in middle-income countries [5]. Globally, approximately 2 billion people suffer from caries in their permanent teeth, and 514 million children experience caries in their primary teeth [6]. The significance of ECC is widely recognized due to its dental, medical, social, and economic impacts. ECC has a complex etiology and tends to progress more rapidly than caries in permanent teeth [7]. Key factors contributing to ECC include the health-related behaviors and practices of families, particularly those of mothers and/or caregivers [8].
Inappropriate feeding practices can lead to a typical pattern of "nursing caries" [9]. For instance, a child who receives a bottle of milk or another sweetened liquid at bedtime, or who frequently uses a bottle or "sippy" cup containing sweetened fluids before or after meals, is at risk. Such practices allow sweetened liquid to pool around the teeth, which, combined with oral bacteria, produces acidic by-products that demineralize and erode tooth enamel over time, ultimately leading to decay. Studies by authors such as Arora et al. [10] and Dahas et al. [11] have elucidated this relationship between feeding practices and children's dental health.
The WHO's comprehensive manual on ending childhood dental caries provides detailed insights into ECC’s extensive impact on oral and general health, quality of life, and socio-economic implications for families and societies [12]. Key risk factors identified include inadequate exclusive breastfeeding, high intake of free sugars, and limited exposure to fluoride, all of which contribute to ECC prevalence [13]. This highlights the need for robust public health interventions and educational initiatives.
The incidence of ECC is notably higher among bottle-fed children, particularly those who are given sugared milk at night [14]. This disparity underscores the importance of public awareness of ECC and the health of primary teeth. While most research indicates a higher susceptibility to caries among bottle-fed infants compared to breastfed ones, some studies report no significant correlation between feeding methods and ECC prevalence [15]. Establishing Infant Oral Health programs is essential, focusing on preventive education and dental care from infancy [16]. This study aims to assess the level of knowledge among mothers of breastfed versus bottle-fed children regarding the prevention of dental caries.
Material and Methods
Study Design and Ethical Clearance
In the current cross-sectional study, the knowledge levels of breastfeeding and bottle-feeding mothers regarding the prevention of early childhood caries (ECC) in their children were investigated. The study was carried out in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Institutional Review Board Committee for Research Ethics at the Deanship of Scientific Research, Qassim University, ensuring that ethical standards were upheld throughout the research process (Reg Number:24-73-05). All mothers were given an Arabic consent form to complete before the study's commencement.
Study Setting, Participants, and Eligibility Criteria
A total of 340 mothers visiting the dental clinics at the College of Dentistry, Qassim University, Saudi Arabia, were recruited to participate in the study. Mothers aged 20-49, currently breastfeeding or bottle-feeding, and able to understand and respond to the survey in Arabic, were included. Exclusion criteria were set for non-breastfeeding or bottle-feeding mothers and those unable to comprehend or respond due to language barriers or cognitive impairments. Convenience sampling was utilised, recruiting participants from mothers visiting the dental hospital during the study period.
Data Collection and Measurement
Data were collected using questionnaires distributed to mothers in the dental clinic setting. These questionnaires, which included details on socio-demographic background, birth-related information, and knowledge about the dental health of toddlers, were adapted from a previous study and translated into Arabic to ensure clarity for participants [17]. The questionnaire used in the study covered various aspects related to maternal knowledge and practices concerning child dental health. It included questions on socio-demographic backgrounds, birth-related details, and awareness levels regarding dental hygiene for toddlers. Specific topics addressed in the questionnaire encompassed previous knowledge of child dental prevention, awareness of children's dental caries due to lactation, recommendations for dental appointments and oral hygiene practices, perceptions about the development of tooth decay in young children, understanding of sugar content in formula milk, beliefs about nocturnal breastfeeding's association with tooth decay, opinions on the effect of bottle feeding on caries development, habits such as tasting food before giving it to infants, and awareness of the potential for maternal dental health to impact the baby's oral health during pregnancy.
The questionnaire underwent a pilot study involving 20 breastfeeding mothers to assess its reliability, validity, and comprehensibility. The questionnaire exhibited high levels of reliability, with a Cronbach's alpha coefficient of 0.85 indicating strong internal consistency among items. Test-retest reliability yielded a correlation coefficient of 0.92, indicating stability of responses over time. Participants provided positive feedback on the clarity and structure of the questionnaire, affirming its comprehensibility.
Study Size
The sample size was calculated using G Power software. Based on the power of a previously published article by Fatani et al., the lowest prevalence was used to determine the sample size [18]. The observed prevalence of the protective stabilization technique (71%) and the expected prevalence (60%) were considered for the calculation. Considering an expected power of the study (0.95) and a 95% confidence interval, the sample size was calculated to be 337 participants with an effect size of 0.423. However, the total sample size was set at 340 mothers to mitigate any potential dropout or bias.
Statistical Analysis
Data analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 25.0. The categorical data were summarised by using frequencies and percentages. Descriptive statistics and Chi-square tests to elucidate potential associations between various maternal characteristics and their knowledge regarding ECC prevention in children. A p-value<0.05 was considered statistically significant.
Results
This study aimed to evaluate maternal knowledge about preventing dental caries in breastfed and bottle-fed children. Table 1 provides detailed socio-demographic information, showing that most participants were in the 30-39 age range. The data also highlight diverse lactation practices among participants, including exclusive breastfeeding, bottle feeding, and mixed feeding. Additionally, the table includes information on occupation, education, income, and the number of children.
Table 2 presents the range of knowledge levels among mothers regarding toddler dental health and prevention. Findings indicate that the majority of mothers possess an acceptable to high level of knowledge about child dental prevention. While mothers showed varying opinions on the ideal age for a child’s first dental visit, there was a general awareness of the link between lactation and dental caries.
Knowledge of breastfeeding mothers about the prevention and health of their toddlers’ teeth.
Table 3 compares the knowledge of mothers with one child versus those with multiple children regarding toddler dental health. Results suggest a higher percentage of knowledge among mothers with multiple children in areas such as understanding of tooth decay and oral hygiene practices. For example, 84.5% of mothers with multiple children demonstrated an acceptable level of understanding about child dental prevention, compared to 15.5% of first-time mothers. Similarly, a larger proportion of mothers with multiple children (85.7%) were aware of the association between lactation and dental caries. However, there were no significant differences between the two groups, indicating a comparable level of awareness (p>0.05).
Comparison between mothers with one child vs. multiple children in knowledge about the prevention and health of their toddlers’ teeth.
Table 4 highlights the influence of maternal education level on knowledge about caries prevention and toddler dental health. A higher proportion of mothers with higher education displayed a better understanding of dental health issues compared to those with lower education levels. For instance, 68.6% of academically educated mothers had an acceptable level of knowledge about child dental prevention, and 78.1% were aware of the connection between lactation and dental caries, a significantly higher awareness compared to mothers with lower education levels.
Comparison between mothers according to education levels in knowledge about caries prevention and the health of their toddlers’ teeth.
In examining the impact of income levels on maternal knowledge about caries prevention and toddler dental health, the study revealed significant differences in specific areas. Knowledge about the sugar content in formula milk varied notably across income groups (p<0.01), indicating a significant disparity in awareness among mothers from different financial backgrounds. Similarly, understanding the effect of bottle-feeding on caries development also varied significantly with income levels (p<0.01), as shown in Table 5.
Comparison between mothers according to income levels (US$) in knowledge about caries prevention and the health of their toddlers’ teeth.
Regarding the influence of lactation type on maternal knowledge, the study identified significant differences in certain knowledge areas. For instance, in the category of "Previous knowledge of child dental prevention," a considerable proportion of mothers practicing mixed feeding demonstrated limited understanding (p=0.002). Awareness of the sugar content in formula milk also varied significantly among mothers based on their lactation type (p=0.02). These findings suggest that while lactation method can substantially influence maternal knowledge in specific areas, its impact is not consistent across all domains of dental health knowledge (Table 6).
Comparison between mothers according to type of lactation in knowledge about caries prevention and the health of their toddlers’ teeth.
Discussion
The study aimed to evaluate the knowledge among mothers who breastfeed and bottle-feed their children about preventing dental caries, with a focus on the widespread issue in pediatric dentistry known as Early Childhood Caries (ECC). The study findings revealed a mixed level of understanding among mothers, with many showing acceptable to high knowledge about child dental prevention and awareness of dental caries due to lactation. However, areas like the timing of the first dental visit and understanding of nocturnal breastfeeding in caries development showed gaps in knowledge. These findings are in alignment with the findings of previous studies like those of Hsu et al. [19] and Hashim et al. [20], which underscore similar concerns.
The socio-demographic findings of the current study indicated that the largest group of participating mothers was aged 30-39, primarily employed, with an academic education, and predominantly practicing mixed feeding. The level of knowledge varied, with a notable number of mothers having an accepted level of understanding about child dental prevention, which is similar to the results found in studies conducted by Kharouba et al. [17] and Shetty et al. [21]. The present study revealed that mothers with higher education levels generally possessed greater knowledge about dental health, a finding consistent with Abuduljalil and Abuaffan [22] research, which also noted a significant correlation between educational attainment and dental health knowledge. Although their study focused on urban mothers, our findings revealed comparable patterns even in semi-urban settings, suggesting that education level, rather than geographic location, is the primary determinant of ECC-related knowledge [22].
In the present study, it was found that while most mothers had an acceptable level of knowledge about child dental prevention, there were clear gaps, particularly in understanding the ideal timing for a child's first dental visit and the transmission of caries-causing bacteria. This finding is similar to the study results from Dhull et al. [23], who also reported a lack of awareness among mothers regarding the appropriate age for a child's first dental visit. Indicating a broad need for improved maternal education in these crucial areas of ECC prevention [23]. Additionally, the present study noted misconceptions among mothers regarding the relationship between nocturnal breastfeeding and caries, in contrast with Branger et al. [24] findings, which suggested a protective role of breastfeeding against dental caries. This discrepancy highlights the need for nuanced educational messages that balance the benefits of breastfeeding with proper oral hygiene practices [24].
In the current study, significant variations in knowledge about the sugar content in formula milk and the impact of bottle feeding on dental health were observed across different income groups. These findings are in alignment with a study conducted by Nassar et al. [25], who also observed significant disparities in ECC awareness among different income groups. These results highlight socio-economic factors as key determinants in parental awareness and attitudes toward ECC prevention [25].
However, the present study also highlighted certain limitations, including its cross-sectional nature, reliance on self-reported data, and potential lack of diversity in the sample. The reliance on self-reported data introduces potential response bias, as participants may overstate their knowledge or understanding of ECC-related topics. These aspects limited the ability to establish causality and generalize findings. Future studies could incorporate longitudinal broader demographic designs, and objective measures, such as assessments by dental professionals to overcome these limitations.
The current study emphasizes the necessity for a targeted educational program for mothers with limited education to address the identified knowledge gaps-such as the timing of the first dental visit and the effects of nocturnal breastfeeding on caries-which is paramount. Furthermore, focusing on practical tips like brushing techniques, dietary choices, and understanding carries risks. hese gaps indicate a significant lack of awareness among mothers, which directly impacts ECC prevention and management. Addressing these issues through well-structured educational interventions could substantially improve pediatric oral health outcomes.
Conclusion
This present study enhances the understanding of maternal knowledge about preventing dental caries, highlighting the significance of a mother’s education and socio-economic status. Mothers exhibit knowledge deficiencies in the timing of the first dental visit, understanding of the impact of nocturnal breastfeeding, transmission of caries-causing bacteria, variations across socio-demographic groups, misconceptions about breastfeeding and dental health, and limited awareness of the impact of maternal oral health during pregnancy. The gaps in knowledge have been identified as pointing to the necessity of targeted educational programs, particularly in areas like the timing of dental appointments and the effects of different feeding practices on children's dental health. These educational efforts are crucial to improve overall dental health in children.
-
Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
Acknowledgments
The authors would like to thank all participating mothers for their outstanding assistance in this study.
References
-
[1] Fewtrell MS, Morgan JB, Duggan C, Gunnlaugsson G, Hibberd PL, Lucas A, et al. Optimal duration of exclusive breastfeeding: What is the evidence to support current recommendations?. Am J Clin Nutr 2007; 85(2):635S-638S. https://doi.org/10.1093/ajcn/85.2.635S
» https://doi.org/10.1093/ajcn/85.2.635S -
[2] Anil S, Anand PS. Early childhood caries: Prevalence, risk factors, and prevention. Front Pediatr 2017; 5:157. https://doi.org/10.3389/fped.2017.00157
» https://doi.org/10.3389/fped.2017.00157 -
[3] Abbass MM, Mahmoud SA, El Moshy S, Rady D, AbuBakr N, Radwan IA, et al. The prevalence of dental caries among Egyptian children and adolescences and its association with age, socioeconomic status, dietary habits and other risk factors. A cross-sectional study. F1000Res 2019; 8:8. https://doi.org/10.12688/f1000research.17047.1
» https://doi.org/10.12688/f1000research.17047.1 -
[4] Kazeminia M, Abdi A, Shohaimi S, Jalali R, Vaisi-Raygani A, Salari N, et al. Dental caries in primary and permanent teeth in children’s worldwide, 1995 to 2019: A systematic review and meta-analysis. Head Face Med 2020; 16(1):22. https://doi.org/10.1186/s13005-020-00237-z
» https://doi.org/10.1186/s13005-020-00237-z -
[5] Sharif H, Hammash M, Anwer W, Hassan N, Seemi T, Sheikh SS. Evaluation of oral health among persons with multimorbidity in the marginalized population of Karachi, Pakistan: A multicenter cross-sectional study. J Taibah Univ Med Sci 2024; 19(3):500-515. https://doi.org/10.1016/j.jtumed.2024.03.008
» https://doi.org/10.1016/j.jtumed.2024.03.008 -
[6] Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of untreated caries: A systematic review and metaregression. J Dent Res 2015; 94(5):650-658. https://doi.org/10.1177/0022034515573272
» https://doi.org/10.1177/0022034515573272 -
[7] Davies GN. Early childhood caries-A synopsis. Community Dent Oral Epidemiol 1998; 26(S1):106-116. https://doi.org/10.1111/j.1600-0528.1998.tb02102.x
» https://doi.org/10.1111/j.1600-0528.1998.tb02102.x -
[8] Hui Bin SU, Zhang W, Zhou XB. Risk factors associated with early childhood caries. Chin J Dent Res 2017; 20(2):97-104. https://doi.org/10.3290/j.cjdr.a38274
» https://doi.org/10.3290/j.cjdr.a38274 - [9] Tinanoff N, O'Sullivan DM. Early childhood caries: Overview and recent findings. Pediatr Dent 1997; 19(1):12-16.
-
[10] Arora A, Scott JA, Bhole S, Do L, Schwarz E, Blinkhorn AS. Early childhood feeding practices and dental caries in preschool children: A multi-centre birth cohort study. BMC Public Health 2011; 11:1-7. https://doi.org/10.1186/1471-2458-11-28
» https://doi.org/10.1186/1471-2458-11-28 -
[11] Dahas ZA, Khormi HA, Vishwanathaiah S, Maganur P, Owis AA, Khanagar SB, et al. Correlation of feeding practices and dental caries among preschool children of Jazan, KSA: A cross-sectional study. Int J Clin Pediatr Dent 2020; 13(4):327. https://doi.org/10.5005/jp-journals-10005-1784
» https://doi.org/10.5005/jp-journals-10005-1784 -
[12] Edem AP. Early childhood caries update. In: Akarslan Z. Dental Caries - Diagnosis, Prevention and Management. London: IntechOpen; 2018. Available from: https://doi.org/10.5772/intechopen.76300 [Accessed on May 18, 2024].
» https://doi.org/10.5772/intechopen.76300 -
[13] Moynihan P, Tanner LM, Holmes RD, Hillier-Brown F, Mashayekhi A, Kelly SA, et al. Systematic review of evidence pertaining to factors that modify risk of early childhood caries. JDR Clin Trans Res 2019; 4(3):202-216. https://doi.org/10.1177/2380084418824262
» https://doi.org/10.1177/2380084418824262 -
[14] Olatosi OO, Inem V, Sofola OO, Prakash P, Sote EO. The prevalence of early childhood caries and its associated risk factors among preschool children referred to a tertiary care institution. Niger J Clin Pract 2015; 18(4):493-501. https://doi.org/10.4103/1119-3077.156887
» https://doi.org/10.4103/1119-3077.156887 -
[15] Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and bottle feeding as risk factors for dental caries: A systematic review and meta-analysis. PLoS One 2015; 10(11):e0142922. https://doi.org/10.1371/journal.pone.0142922
» https://doi.org/10.1371/journal.pone.0142922 -
[16] Mouradian WE, Wehr E, Crall JJ. Disparities in children's oral health and access to dental care. JAMA 2000; 284(20):2625-2631. https://doi.org/10.1001/jama.284.20.2625
» https://doi.org/10.1001/jama.284.20.2625 -
[17] Kharouba J, Mansour S, Ratson T, Naishlos S, Weissman G, Blumer S. Knowledge of breastfeeding mothers regarding caries prevention in toddlers. Children 2023; 10(1):136. https://doi.org/10.3390/children10010136
» https://doi.org/10.3390/children10010136 -
[18] Fatani EJ, Almutairi HH, Alharbi AO, Alnakhli YO, Divakar DD, Alkheraif AA, et al. In vitro assessment of stainless steel orthodontic brackets coated with titanium oxide mixed Ag for anti-adherent and antibacterial properties against Streptococcus mutans and Porphyromonas gingivalis. Microb Pathog 2017; 112:190-194. https://doi.org/10.3390/children10010136
» https://doi.org/10.3390/children10010136 - [19] Hsu KL, Dhar V, Tinanoff N. Worldwide variations in methodology and reporting of early childhood caries: A scoping review. Pediatr Dent 2021; 43(5):349-368.
- [20] Hashim R, Fitzgerald R, Schafer C, Thomson WM. Mothers’ understanding of dental caries-related feeding practices and children’s use of dental care in Ajman. Soc Sci Dent 2011; 1:97-107.
-
[21] Shetty RM, Deoghare A, Rath S, Sarda R, Tamrakar A. Influence of mother′ s oral health care knowledge on oral health status of their preschool child. Saudi J Oral Sci 2016; 3(1):12-16. https://doi.org/10.4103/1658-6816.174291
» https://doi.org/10.4103/1658-6816.174291 -
[22] Abduljalil HS, Abuaffan AH. Knowledge and practice of mothers in relation to dental health of pre-school children. Adv Genet Eng 2016; 5(2):1-7. https://doi.org/10.4172/2169-0111.1000153
» https://doi.org/10.4172/2169-0111.1000153 -
[23] Dhull KS, Dutta B, Devraj IM, Samir PV. Knowledge, attitude, and practice of mothers towards infant oral healthcare. Int J Clin Pediatr Dent 2018; 11(5):435. https://doi.org/10.5005/jp-journals-10005-1553
» https://doi.org/10.5005/jp-journals-10005-1553 -
[24] Branger B, Camelot F, Droz D, Houbiers B, Marchalot A, Bruel H, et al. Breastfeeding and early childhood caries. Review of the literature, recommendations, and prevention. Archives de Pédiatrie 2019; 26(8):497-503. https://doi.org/10.1016/j.arcped.2019.10.004
» https://doi.org/10.1016/j.arcped.2019.10.004 -
[25] Nassar AA, Fatani BA, Almobarak OT, Alotaibi SI, Alhazmi RA, Marghalani AA. Knowledge, attitude, and behavior of parents regarding early childhood caries prevention of preschool children in Western region of Saudi Arabia: A cross-sectional study. Dent J 2022; 10(12):218. https://doi.org/10.3390/dj10120218
» https://doi.org/10.3390/dj10120218
Edited by
-
Academic Editor:
Catarina Ribeiro Barros Alencar
