Impact of oral health conditions on the quality of life of preschool children and their families: a cross-sectional study

Oral health conditions can have a negative impact on the functional, social and psychological wellbeing of young children and their families, causing pain and discomfort for the child [1, 2]. Assessing the impact of oral health on the life quality of children can improve communication between patients, parents and the dental team and can provide an outcome measure for clinicians to assess the quality of care. Moreover, the evaluation of oral health-related quality of life (OHRQoL) can assist in the assessment of treatment needs, the prioritisation of care and the evaluation of the outcomes of treatment strategies and initiatives [3‐5].

The interest in the assessment of OHRQoL among children has grown in recent years, which is a major improvement, as children in many communities around the world are affected by dental caries, traumatic dental injury (TDI) and malocclusion [2, 4‐9]. Recent studies carried out in Brazil have shown high prevalence rates of adverse oral conditions, especially in areas with social inequalities, such as the area in which the present study was conducted [10‐12].

The Early Childhood Oral Health Impact Scale (ECOHIS) was developed to assess the impact of oral health conditions on the quality of life of preschool children (aged 2 to 5 years) and their families and has been validated in Portuguese for use on Brazilian populations [1, 13, 14]. This scale is a proxy measure that considers parents/caregivers to be fundamental in the treatment decision-making process and perceptions regarding children’s oral health conditions [1, 13]. Moreover evidence in the fields of child development and psychology indicates that children less than six years of age are incapable of accurately recalling day-to-day events after more than 24 hours [15].

Studies evaluating the impact of oral health conditions on OHRQoL are often based on non-randomised [5‐7] convenience samples [9, 16, 17]. Moreover, most studies use dichotomised variables (presence/absence of oral health conditions) [2, 9, 16, 17]. Few studies have stratified the variables based on the severity of TDI and types of malocclusion [5, 7] and all studies have evaluated dental caries using the WHO criteria, which does not discriminate cavitated dental caries and the initial stages of dental caries (e.g., white spots). No study in the literature has evaluated the severity of dental caries based on new diagnostic index for dental caries: the International Caries Detection and Assessment System (ICDAS), which is an internationally accepted caries detection system that allows the assessment of initial carious lesions (white spots) on the enamel and active lesions in the dentine. This system is based on the combined knowledge of the clinical appearance of the lesion, whether the lesion is in a plaque stagnation area and tactile sensation (texture) when a round-tipped probe is gently drawn across the surface of the tooth [18, 19]. No study has evaluated the impact of white spots and cavitations on OHRQoL. Furthermore, the present investigation is a unique representative, randomised study with a two-stage sampling method and hierarchical analysis to evaluate the impact of the severity of TDI, type of malocclusion, white spots and cavitated dental caries on OHRQoL.

The aim of the present study was to evaluate the impact of oral health conditions on the OHRQoL of preschool children aged three to five years and their families in a representative, preschool-based sample.

A total of 843 pairs of preschool children and their parents/caregivers participated in the present study, corresponding to 97.5% of the total determined by the sample size calculation. The loss of 21 children was due to a lack of cooperation during the exam (n = 6), incomplete questionnaires (n = 11) and absence from preschool on the days scheduled for the clinical examinations (n = 4).

Table 1 displays the oral health conditions distributed according to the socio-demographic data of the sample. The chi-square test revealed that, among the three oral conditions, only cavitated lesions were significantly associated with age, type of school, mother’s schooling and monthly household income. More children with cavitated lesions were aged five years (56.8%), studied at public preschools (58.6%), had mothers with ≤ eight years of schooling (62.4%) or came from families that earned up to the minimum wage (61.1%) compared to children with white spots or without dental caries. Parents’/caregivers’ perceptions of general and oral health were poor among 81.0% and 66.5% of the sample, respectively.

The prevalence of negative impact on OHRQoL was 32.1% among the children and 26.2% among the families. Scores of 0 (floor effect) were found on 58.6% and 69.6% of the Child Impact and Family Impact sections of the B-ECOHIS, respectively (i.e., 58.6% and 69.6% of the parents/caregivers reported no impacts). No ceiling effect was found for either section (i.e., scores of 36 and 16 on the Child and Family Impact sections, respectively). The maximum score was 31 on the Child Impact section and 14 on the Family Impact section (Table 2). Table 2 also displays the mean, standard deviation, median, minimum and maximum total B-ECOHIS scores and subscales scores. The items with the highest means were “reported pain”, “felt guilty” and “been upset”.

In the final hierarchical Poisson regression model, the following variables were significantly associated with a negative impact on OHRQoL among the children: child’s order of birth, parent’s/caregiver’s perception of child’s oral health as poor, cavitated dental caries and TDI (Table 3). The following variables were significantly associated with a negative impact on OHRQoL among the families: parent’s/caregiver’s perception of child’s oral health as poor, cavitated dental caries and greater severity of TDI (Table 4).

The present study evaluated the impact of dental caries, TDI and malocclusion on the OHRQoL of preschool children using the Brazilian Portuguese version of the ECOHIS. The occurrence of cavitated lesions and TDI was found to cause a negative impact on the OHRQoL of preschool children and their families, whereas different types of malocclusion did not have this effect. Moreover, this is the first study to perform a hierarchical approach, which stratifies the impact of the severity of TDI, different types of malocclusion, different stages of dental caries and the teeth affected as risk factors that exert an influence on quality of life. Such an approach allows an analysis of interrelationships among factors rather than making the strict statistical associations commonly found in multivariate methods [27].

Cavitated lesions were associated with OHRQoL among the children and families due to the fact that parents/caregivers recognise an oral health problem when it becomes evident or when it is manifested in the form of pain [28, 29]. Indeed, the parents/caregivers reported greater impact on the items “reported pain”, “difficulty drinking hot or cold beverages”, “difficulty eating some foods” and “been irritable”. These findings indicate symptoms related to more serious oral health problems, such as untreated dental caries [30]. Severe dental caries can result in parents/caregivers missing days of work and greater financial expenditures as well as feelings of guilt, with a consequent negative impact on the OHRQoL of the family [17, 28]. Moreover, the greater participation of women in the job market and consequent reduction in the role mothers play in raising their children [31] may have contributed to the greater frequency of the items “felt guilty” and “been upset”, as suggested in previous studies [2, 8, 17]. It should be stressed that dental caries was diagnosed in the present study using the criteria of the ICDAS-II, which detects the early manifestations of this condition [18]. This may explain why the presence of dental caries when considering data on white spots was not associated with OHRQoL, as such lesions often go unperceived by parents/caregivers and do not cause pain. Cavitated teeth have been associated to a negative impact on OHRQoL in previous investigations [2, 5, 6, 17, 29], although the location of the lesions was not evaluated in the studies cited. Cavitated lesions on anterior teeth were not associated with a negative impact on OHRQoL, likely due to the nature of these lesions, which were not very severe, and the lesser importance given to aesthetics in the age group analysed [32]. However, when posterior teeth and both posterior and anterior teeth were analysed, significant associations were found with a negative impact on OHRQoL, possibly because cavities on posterior teeth are generally more severe and associated with reports of pain and difficulty eating [28, 30].

Cavitated lesions were associated with socio-demographic variables (lower income, lower educational level of the mother, enrolment at a public preschool and children aged five years) in comparison to children with white spots or without dental caries. This demonstrates the importance of socio-demographic data regarding the use of dental services [33, 34]. Some studies have found a greater frequency of impact on the OHRQoL of preschool children from families with a lower socioeconomic status [2, 6, 17]. However, no socioeconomic variable remained associated with the negative impact on quality of life in the present investigation, which is in agreement with data reported in a previous study [5]. This finding suggests that oral health conditions can exert an impact on the quality of life of children regardless of one’s socioeconomic status.

While a previous investigation found an association between malocclusion and impact on OHRQoL [5], the majority of studies found no such association [2, 7, 9, 17, 35], which is in agreement with the present findings. However, TDI had a negative impact on the OHRQoL of the preschool children and cases of avulsion and/or luxation were predictors of a negative impact on the OHRQoL of the families. This type of oral health problem may require a considerable amount of time on the part of the family due to the urgency of relieving the pain symptoms and the limitations that may arise [5, 9, 28]. Parents/caregivers generally perceive a negative impact on quality of life when clinical signs are involved, such as tooth discolouration, which can exert a psychosocial impact on the child [8]. However, some studies have found no association between TDI and OHRQoL [2, 8, 17]. This may be due to the type of TDI considered in the analysis, as negative impact generally only occurs in more serious cases [7, 9, 28].

Birth order of the child was a predictor of a greater negative impact on OHRQoL among the children, likely because financial resources and attention from parents/caregivers are shared among the siblings as more children are born into the family [36, 37]. Indeed, a greater frequency of dental caries is found among children in large families [38].

Parents’/caregivers’ perception of their child’s oral health was associated with a negative impact on the OHRQoL of both the children and families. Perceptions of parents/caregivers regarding their child’s oral health plays an important role in the determination of the negative impact on OHRQoL [39], as the health of preschool children depends on parental/caregiver knowledge regarding health care [40].

The present study has the limitations inherent to the cross-sectional design and the answers on the questionnaires may have been subject to information bias. However, a number of measures were taken to diminish the occurrence of such bias, such as the use of a validated questionnaire and the execution of a pilot study. Thus, it is possible to extrapolate the findings, since the present investigation was a representative, preschool-based study. Longitudinal studies are needed to clarify the relationship of causality and allow establishment of public policies aimed at reducing the impact of oral health conditions on the OHRQoL of preschool children and their families.

Cavitated lesions on anterior and posterior teeth, traumatic dental injuries and parents’/caregivers’ perception of their child’s oral health as poor are determinants of a negative impact on the OHRQoL of preschool children and their families. While white spots were not associated with impact on OHRQoL, it is important to treat such cases to prevent the progression to cavitation.