Background
Dental caries is the most prevalent oral health problem, affecting a large number of people worldwide [
1]. Early childhood caries (ECC) is defined as the presence of one or more teeth with cavities, missing, or restored because of caries in children younger than 72 months. This oral health problem is a global health burden, medically, socially, and economically [
1,
2]. Indonesian national oral health insurance allows all Indonesian to access healthcare [
3]. But, Indonesia has the highest prevalence of ECC among several other countries, with 90% in the 5-year-old children population [
4]. Jakarta, as the capital city of Indonesia, is different from other provinces, where there is a lack of remote population and different gross domestic product and healthcare structure [
5]. According to a spatial analysis in 2021, Jakarta has the most dentist in each public health center work area in Indonesia, along with the unevenly distributed private Indonesian dentists are centralized in this city [
6,
7]. Even though it still has several limitations, inequality analysis showed that Jakarta had one of the lowest levels of health inequality in Indonesia (3.1% compared to 92.3% in the Province of Papua) [
8,
9]. So, access to oral healthcare services in Jakarta is relatively adequate compared with other parts of the country. Yet, the prevalence of oral health problems in the city is still high [
10].
ECC is a serious condition that has a negative impact on young children’s quality of life. Their primary caregivers, usually their mothers, play a crucial role in taking care of their health [
11,
12]. Mothers play an important role in providing effective guidance and positive attitudes toward oral health [
11]. In five years old children, the primary dentition represent the late stage and can be used to evaluate the efficacy of previous oral healthcare behavior. Identifying problems at this stage may help to prevent future oral health problems [
13].
Health needs are defined as the degree of health disease that potential users of healthcare experience [
14]. Along with the recognition of health as a subjective state, the self-perceived need for oral health care is just as important [
15]. A perceived need that is different from the actual oral health status indicates unawareness, which must be overcome [
16]. Regardless of the clinical parameters, multiple variables, such as socioeconomic factors and oral health literacy, could determine individual perceived needs [
15,
17]. The perceived need for dental care and parents’ awareness of their child’s health will determine whether they seek dental care.
Aside from being a useful parameter of individual awareness, self-rated oral health status is also useful in epidemiological surveys, where clinical examinations, especially in large populations, are impractical and costly. One of the most efficient methods for obtaining oral health data in a population is through self-report, which reflects their perceptions of oral health status and the perceived need of care [
15]. It is important to compare perceived and evaluated needs across populations and groups because subjective assessments may vary depending on individual beliefs and awareness, oral health, social, educational, cultural background, and environmental conditions [
15,
16]. To date, no study has assessed the difference between the mother and child self-perceived and dentist-evaluated needs of 5-year-olds in Indonesia. This study aimed to compare the oral healthcare needs of children aged five years old in Jakarta, Indonesia, as perceived by mothers, children and clinically evaluated. Furthermore, the accuracy of the mother- and child-perceived oral health compared to the clinical assessment as the gold standard was analyzed.
Results
This study analyzed data from 266 pairs of mothers and children, with almost equal numbers of male (n = 134) and female (n = 132) children. Most mothers who participated in this study had 2 or 3 children and attended high school as their highest educational attainment. Intraoral examination revealed that from the total sample, the children’s mean dmft score was 7.7± 5.5 and the pufa score was 0.9±1.7. Almost all children had decayed teeth, with 28.6% (n = 76) and 60.1% (n = 160) of them having ECC and severe-ECC, respectively [
22]. In addition, the pufa index showed that 35% of the children had at least one condition resulting from untreated caries [
23].
Table
1 shows the mothers’ and children’s perceptions of their child’s oral health, with lower scores indicating more positive ratings. On a scale of 0 to 2, most children were happy with the condition of their teeth (0.48±0.64). More than half of them (55%; n = 147) claimed they did not have oral cavities. Most mothers thought that their child’s oral health was relatively good (1.57±1.55; on a scale of 0–4), but 68.4% believed that their child needed dental treatment.
Table 1
Mother-Child Self-Perceived Oral Health of Children (n = 266)
Self-Perceived Oral Health of Children
| | |
Self-rated oral health (0–2) | 0.48±0.64 | |
Presence of Dental Cavity | | |
Have cavities
| | 118 (44.4%) |
Did not Have Cavities
| | 147 (55%) |
Mother-Perceived Oral Health of Children
| | |
Mother-rated of their child’s oral health (0–4) | 1.57±1.55 | |
Mother perceived-need of child dental treatment | | |
Need Treatment
| | 182 (68.4%) |
Did not Need Treatment
| | 84 (31.6%) |
Table 2
Sociodemographic characteristics of the study participants (n = 266) and association with clinically assessed oral conditions
Gender of Child | | | | |
Male (134) | 120 (89.6%) | 0.555 | 49 (36.6%) | 0.580 |
Female (132) | 121 (91.7%) | | 44 (33.3%) | |
Number of Children | | | | |
Single (47) | 42 (89.4%) | 0.944 | 14 (29.8%) | 0.675 |
1/2 siblings (198) | 180 (90.9%) | | 70 (68.2%) | |
>2 siblings (20) | 18 (90%) | | 8 (40%) | |
Mother’s education | | | | |
High (102) | 88 (86.3%) | 0.133 | 93 (35%) | 0.752 |
Moderate (103) | 125 (94%) | | 48 (36.1%) | |
Low (31) | 28 (90.3%) | | 12 (38.7%) | |
Table
2 shows the differences between clinical assessment among sociodemographic factors based on sex, parental education level, and the number of siblings; no statistically significant differences were found among them (p > 0.05). Table
3 shows the correlation between the child oral health scores given by mothers and the children with the actual condition measured by the dmft and pufa indices. The Spearman correlation found significant correlations between perceived and evaluated variables (
r = 0.141–0.372). When comparing both perceived variables, The ICC analysis showed only fair agreement between the mothers and their children regarding the child’s oral health (ICC = 0.335).
Table 3
Association between Mother-Child self rated oral health with clinically assessed oral condition in 5-year-old children (n = 266)
Child self-rated oral health | 0.187 |
0.002*
| 0.141 |
0.021*
| 0.335 |
Mother-rated of their child oral health | 0.372 |
< 0.001**
| 0.272 |
< 0.001**
| |
The validity of the mother- and child-perceived need was evaluated using ROC analysis (Table
4). Compared to the pufa index score, the child self-reported tooth decay had the highest AUC score (AUC = 0.67). The sensitivity of child self-reported tooth decay was higher than the specificity when compared to the presence of dental caries (dmft); however, compared to the outcomes of untreated dental caries (pufa), the specificity was higher than the sensitivity. The mothers’ perceived need for dental care had the highest sensitivity (Sn = 96.7%) to the presence of dental caries and the highest specificity (Sp = 88.1%) to pufa. Compared to the pufa index score, the mother-perceived need for dental treatment had the highest LR + of 3.83, and the child-perceived presence of tooth decay had the lowest LR − of 0.67.
Table 4
Validity of the mother- and child-perceived need of oral-health care compared with decay tooth and untreated dental caries complication (n = 266)
Child perceived-presence of dental cavity | 93.6 | 11.6 | 1.06 | 0.51 | 0.561 | 0.442–0.681 | 48.7% | 76.2% | 2.06 | 0.67 | 0.634 | 0.563–0.704 |
Mother perceived-need of child dental treatment | 96.7 | 22.6 | 1.25 | 0.15 | 0.255 | 0.153–0.357 | 45.6% | 88.1% | 3.83 | 0.61 | 0.340 | 0.274–0.405 |
Discussion
In this study, 5-year-old children had a high level of dental caries. At this age, parents, especially mothers as the primary caregiver, play an important role. However, inadequate awareness, low maternal oral health literacy, and the mother’s lack of locus of control are associated with children having dental caries and adverse early childhood oral health outcomes [
17]. These factors may influence the perceived need for children’s dental care and whether they have a good oral health behavior.
A previous study found that the child’s sex and the mother’s education were both associated with a high prevalence of caries in children [
27,
28]. Having siblings also has been linked to decreased dental visits and oral health-related quality of life [
29]. But, this present study showed no statistically significant differences in clinically assessed decay and pufa between different sex, the number of siblings, or maternal education.
Self-perceived assessment is becoming more popular in oral health studies [
25]. As a screening test, self-perceived need assessment is not invasive, less expensive, less time-consuming, and less discomforting for patients. Although these tests are known to be unreliable and ambiguous, the extent of their accuracy must be determined to encourage appropriate interpretation and decision-making [
15,
25]. In young children, their mothers usually act as their proxies [
30‐
32]. However, several studies have discussed children’s self-report capacity, which assumed that children as young as eight years already have mental functions for accurate self-evaluations [
20]. Another study even suggested that children as young as 4–6 could accurately describe their conditions in specific domains such as dysfunction and pain [
33].
Although it is widely accepted that children under the age of five cannot reliably self-report, clinical practice has considered children’s perceptions of their disease and opinions about their treatment [
37]. The cut-off age for this study was set at five years old, at which children are considered capable of reporting their condition. This population already has social and emotional capacities such as communication, self-confidence, self-control, cooperation, curiosity, and intellectual skills [
38]. However, we also acknowledge that 5-year-old children, even those from the same population, are not always developmentally identical [
20]. A child’s characteristics and maturity are influenced by various factors, including the parents’ behavior and beliefs, which later provide an environmental framework for children’s psychosocial growth also shape their behavior and perceptions [
39]. Nonetheless, it is necessary to determine how far 5-year-old children and their mothers in Indonesia can report their oral health condition.
Children and their mothers’ recognition of oral health problems may be related to the oral health-related quality of life (OHRQoL) they experienced. Pakkhesael et al. (2021), in Iran, found that parents are more concerned about their toddler’s oral health and have lower OHRQoL due to increased dmft [
34]. In Indonesia, Ramadhani et al. (2021) also found that children’s and parents’ perceptions of their OHRQoL are related to the dmft and pufa scores [
19]. Several studies have already been conducted to assess the perceived needs for oral health care in various age groups. In Thailand, the perceived need for dental treatment among school-aged children was related to the number of untreated decayed teeth. It was highly associated with levels of oral impacts, specifically on eating, emotional stability, and smiling performances [
35]. However, Rajput et al. in India discovered that only one-third of children’s parents that dental problems are just as serious as other health problems and considered their child’s oral health was unsatisfactory [
36]. In Indonesia, Maharani et al. in 2019 showed that self-perceived information provided by young adolescents cannot accurately evaluate their oral health conditions [
25].
Among general population, self-report should always be used where possible. However, in young children whose age or cognitive/health status prevents them from reliably self-reporting, proxy reports are a valuable way of obtaining information about them. But, multiple studies have found inconsistencies between under and over-estimation among proxy reports [
37]. Previous research has shown that parental ratings are usually worse than children’s self-ratings. Mothers are more accurate in indicating their children’s health and clinical needs, especially in observable conditions [
20,
29,
33]. According to this study, mother and child only have a fair agreement regarding children’s oral health condition. So, obtaining information from both whenever possible should be encouraged to avoid the loss of information.
When compared to both mother and child perceptions of oral health needs, the pufa index showed higher specificity than sensitivity. The higher specificity (ability to identify true positives) of the pufa index may be highly related to the child’s pain as a complication of untreated caries, making both mother and child aware of the actual problem [
23]. Thus, dental caries and the need for oral health care were not recognized until the lesion was already extensive and painful. At that time, the disease required a more invasive procedure [
31].
On the contrary, the sensitivity (ability to identify true negatives) of mothers’ assessment was the highest compared to tooth decay’s actual presence. However, the high prevalence of dental caries among respondents may mask the false positives. The higher sensitivity of the dmft index and specificity of the pufa index were similar to a previous study in Jakarta but in a different age group (12–15 years old) [
15]. Thus, compared to the dmft index, the pufa index used in the clinical assessment may have reduced the likelihood of false-positive reports. Nonetheless, the few shortcomings of the pufa index, such as closed fistulae, which are often not visible on intraoral examination, should not be overlooked [
40].
The main finding of this study is that several accuracy parameters (AUC, Sn, and Sp) did not meet the acceptable threshold [
15,
26]. This finding indicates that when mothers and children are asked to self-report their oral health, they do not provide accurate information. The correlations between the variables were significant but relatively weak, so they could not be used to predict the actual oral health condition [
20]. However, if the pain is present, both mother and child can identify their problem more easily. This finding is similar to previous studies that found disparities between clinical and self-reported oral health among different populations and age groups [
14‐
16,
25,
35]. This inaccuracy could be attributed to the poor understanding of oral diseases and their associated symptoms. However, this method may have practical applications in epidemiological studies and rapid screening to determine the need for referral to higher-level of health care facilities [
13,
15]
As their children’s primary caregiver, mothers establish their children’s behaviors related to oral health. Mothers’ awareness of their children’s worsening oral health conditions is a key factor in seeking dental treatment [
29]. Promoting oral health awareness can help a person recognize the problem and make positive health-related behavioral changes, even in individuals as young as five years old [
30,
41]. Both mothers’ and children’s oral health awareness should be improved so that they have the better diagnostic ability and can implement preventive measures as early as possible, resulting in better oral health outcomes in the future.
There are several limitations to this study. The sampling method might not have produced a representative sample of children aged 5 years who did not attend school, introducing a selection bias. Second, random errors due to the sampling method could have been present. The results of this study must be inferred carefully from larger populations. Social desirability bias might have been present because of the potential embarrassment of some participants (on certain topics). They may have chosen to provide information that is suitable for their image rather than the actual condition [
42]. Furthermore, other factors not observed in this study could have influenced mothers and their child’s perceived need of oral health care.
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