The group of participants is diverse in terms of their role (47 mothers vs. five fathers), cultural background (Brazilian, Dutch, Eritrean, Moroccan, Philippian, Syrian, Turkish or unknown), employment status (full-time, part-time, or unemployed), number of children per household (1 child up to 7 children) and relationship status (single, married or unknown). Participants were invited via local preschool (n = 14), playgroup (n = 14), societal organisations (n = 6), personal network (n = 9), paediatric dental practice (n = 4), mosque (n = 3) and library (n = 2). Additional File 1 shows a complete overview of the participants.
From the analysis of the data, four themes were derived. Parental views on (1) Daily lives of the families; (2) Meaning of young children’s oral health and associated problems; (3) Parents’ struggles in young children’s oral health; and (4) Opportunities and strategies for child oral health promotion.
Family life with young children is hectic
Most parents say that parenting is not easy. A 27-year-old mother, currently unemployed and taking care of two young children (three and one-year-old), describes parenthood as “It’s the most beautiful thing there is. But it’s also the toughest thing there is […]. Yes, I am very happy. I think it is a very nice situation we are in now, but it is sometimes tough […]. Parenting is just a profession in itself.” A Moroccan mother expresses her concerns about child rearing: “I have [3 children] now, and I am just grateful, but it is very difficult for parenting. […] Parenting is very difficult at this time.” A single mother with a 3.5-year-old son adds: “Being a mother is heavy. Parenting is not easy.”
In most families, fathers work more than mothers do. Therefore, mothers feel highly responsible for their children’s upbringing. A mother with two children describes how she is mainly involved in the upbringing of her two children because of her husband’s working hours: “I actually do most of it by myself, so at some point, it’s just in there, so I know what I’m doing because he is not around as much.” Most mothers do not want to burden their husbands because they have “little energy” at the end of the day. A Turkish mother says that her husband sometimes helps with parenting, but she adds, “He does not spend 24 hours with him, he works, and when he comes home, he also says, ‘I’m tired too’.” A working mother with three children does not expect help because: “I already assume that I just have to do it on my own. And if that involves help from my husband, then that’s fine. But I’m not necessarily waiting for it.”
Mothers share their difficulties in managing their busy and hectic daily lives. They describe an ordinary day as “
intensive”, “
a very long day”, “
a full program”, “
too little time”, and “
exhaustive”. Mothers run around getting their children ready for the day, bringing them on time to preschool or school, picking them up at specific times and taking them to other activities. A mother from Moroccan origin struggles to combine the upbringing of her two children with working. She says, “
It’s always a lot of scheduling and arranging.” Multiple mothers notice that children are nowadays very demanding. A married mother wants to provide enough attention to her youngest daughter but struggles with being fully responsible for the upbringing of her three children and doing all house chores. Mothers do their best to keep structure in their family. An employed and married mother with three children (four, two and one-year-old) tries very hard to maintain structure but:
“You don’t know what can happen. You have broken nights, you have weepy kids in the morning, accidents that can happen, exploded nappies, and all those things affect your schedule, causing you to get completely bogged down with your daily schedule in the morning.”
Parents also say that living in an area characterised as a disadvantaged neighbourhood influences their family life. Mothers complain about the poor housing facilities and current building renovations in the neighbourhood. A pregnant and unemployed mother talks about all the mould in her small student apartment: “Whole bathroom wall, everywhere full of mould”, which she shares with her son (nine months) and husband. A Moroccan mother frustratedly says: “And walls are all broken, a lot of dust, and that is actually not healthy for me and also for my children. My youngest child got eczema from a lot of dust.” On the contrary, a married father is happy about his 60 m2 old apartment, which he shares with his three children, and he adds, “Amsterdam with a single-family home is a bit difficult you understand, so unfortunately, getting single-family home is not for everyone.”
Child oral health is important, but…
Most parents value their children’s oral health when the topic is raised. For parents, oral health in young children means “
healthy teeth”, “
good brushing”, “
healthy food and drinks”, and “
not too many sugars”. A mother born in the Philippines finds oral health of her 19-month-old daughter important because “
good teeth make you smile”. A Syrian mother with five children emphasises in Arabic a good oral health of her youngest son so that “
He can eat enough, [he] can always enjoy his smile, if he is not in pain, if his mouth is not dirty […] then he can have fun with everything.” A mother highly values her daughter’s oral health because of her own problems: “
I think it is important to brush consciously, so I do all the oral health care. So that she doesn’t get such problems with her teeth, I think it’s extra important for her.” A father adds:
“From childhood, oral health is actually the most important thing there is. So we make sure that all of us, so children as well, brush the teeth properly, […] it’s a bit of getting the child used to it from an early age that later on the child will grow up in such a way that they don’t actually say later on of ‘oh yes today brushing teeth, no don’t have to’.”
However, a few parents question the importance of children’s oral health. A Turkish mother notes: “Yes, it is important […] I don’t want him to have cavities later of course. But I’m like, it’s more important after the baby teeth. Those teeth are going to come out anyway.” In a discussion about the relationship between nutrition and teeth, a pregnant mother with seven children says: “Teeth is not in the first place actually, does come second, first place is surely what it does to your body, second place is teeth.” Another mother finds oral health important, but simultaneously mentions that her son’s oral health has a lower priority than playing and his evening meal.
Although parents differ in the perceived importance of their child’s oral health, they all experience oral health problems within their household. A mother expresses her disbelief towards the cavities of her daughter: “[I] brushed many times, and really twice a day, she only drinks water, and still she still has these cavities, and I also just helped there with brushing, it could also just be something, yes, maybe genetic, and even though you do your best.” Another mother frustratedly says that her son experienced cavities at a young age while he didn’t eat candy. A mother talks about oral health problems when her daughter was four months old: “She had gum inflammation. And I didn’t know how that came because it was an awful infection. She was in a lot of pain.” A Moroccan father describes his three-year-old son’s poor oral health while his son is being treated under deep sedation in a paediatric dental practice: “[He] has four big holes, eight molars in the back, then next to that he also has holes, and then the front teeth, he also has all these holes […] So, or in other words, his whole set of teeth is 0.0.”
Limiting candy is a daily challenge
Parents struggle with their children’s preference for candy or unhealthy food. A single mother mentions about her son: “He is really picky with food. He prefers just to eat candy all day”, and she adds that candy is given out of love. Young children tend to ask for candy continuously throughout the day. A mother frequently gives candy to keep her daughter calm so that she can finish her daily house chores. A father with a Moroccan background and five children expresses his concerns: “I always struggle with those fruits and vegetables, struggling for those kids.” And a mother adds: “My children, I can’t control them when there is candy at home.”
Sometimes, controlling children’s candy intake is complicated due to parental clashes. A mother explains: “I don’t buy candy, but my husband also has a bag of candy on top of the cupboard, so once in a while, he gives all the kids candy, too.” Mothers feel that their husbands are more easygoing when offering candy to their children. A Turkish mother frustratedly says her husband tends to give crisps to her children in the morning before breakfast. Another mother, whose three-year-old son has eight cavities, finds it difficult to disrupt her son’s “daddy-moment”, in which they eat unhealthy food just before sleeping.
Also, parents feel challenged by the presence of unhealthy food during family visits. A mother from Moroccan origin describes how she has to control her “
sweet-toothed” daughter when visiting grandparents: “
Then there is cake on the table, then there are biscuits on the table […] if you don’t pay attention for a moment, she has already finished three of them.” Parents struggle to deal with the need from family members to provide young children with something sweet. A mother mentions: “
We were at a party […] at my husband’s family, […] then he [my youngest] got a whole bounty or a snickers in his hands, I almost had a heart attack.” Confronting family members in giving candy is perceived to be hard, as a mother explains:
“I also don’t know what to do when someone gives him something. ‘Yes, give it back’. I just find it awkward. While I see plenty of parents who do so. I feel ashamed again. I find it awkward again to do that in front of someone.”
Some parents perceive Amsterdam New-West, as an unhealthy living environment. A mother struggles to find “easy-accessible healthy food” when having a day out with her three-year-old son. She experiences differences in the availability of healthy food between different neighbourhoods in Amsterdam. A mother who recently moved to Amsterdam New-West recognises this: “I have neighbours here who very often bring candy, which is very sweet for my children […] you just really notice that difference between New West and South […]. Once, I got a book for my son there.” On the contrary, a father believes that living in an unhealthy environment does not influence cavities among young children because “Everywhere you go in the Netherlands you have snack bars, whether it’s in New West or Old South […] it all depends on yourself […] It’s not the snack bar’s fault.” A Surinam-Dutch mother agrees, saying, “Look, of course, there are many snack bars, but you don’t do your groceries there.”
Difficulties with toothbrushing
Many parents express their frustrations with tooth brushing in young children. Children tend to “yell”, “cry”, “vomit”, “scream,” or “refuse” during tooth brushing. A mother talking about her son: “He says: ‘mummy, I’m getting nauseous, no, stop’. Then I have to stop right away.” Young children often do not want to be helped by their parents, resulting in a fight. A mother illustrates: “If I want to brush his back molars, he puts his jaws together, and yes, you try to brush, then you sit there all the time fighting, crying, you name it.” A Dutch mother with a four-year-old daughter adds: “It’s really not fun, you know, […] and then you don’t want that daily hassle around teeth brushing, you know, that you think ‘get those teeth apart now’.”
Sometimes, parents feel too tired to handle their children’s behaviour. A mother tries her best to help her youngest children with brushing, she explains, “Then you get a struggle, and then I get tired, and then I think ‘yeah, bye, just take it easy, you know, never mind’.” A mother adds that her son does not feel like brushing his teeth in the evening because “He’s just tired, then I’m tired, so then I think ‘never mind’.” Another mother mentions that she does not help her three children during brushing when she feels too tired. A mother with a Turkish background feels guilty about feeling tired and says, “It’s only a one-minute work, ‘Couldn’t I keep it up a minute longer?’ Afterwards, you get that feeling of guilt, ‘What if they are going to get cavities?’.”
Due to limited time and busy schedules, parents tend to skip tooth brushing. A mother of three children explains: “
I try twice, but it doesn’t always happen in the morning, I must say, because of the rush and bustle. And I must say that I regret that.” According to a father, “
rush hour in the morning” is the biggest problem. He adds,
“Then they have to eat, and then they have to get dressed et cetera, if we then think ‘we don’t have much time’, then not today.” Brushing is also skipped after a “
tough day” or a “
long hard day” and illustrated in Turkish by a mother:
“You run there and then there again, and you are completely exhausted at the end of the day. A person gets very tired from that, so even for brushing your teeth, there is no time left, so then you would just prefer to lie in bed.”
Limited support in children’s oral health
Often, mothers pay the most attention to establishing good oral health habits for their children and lack support from their husbands. A Moroccan mother explains, “My husband really doesn’t think about that [her daughter’s teeth] […] he thinks ‘whatever’ […] Yes, in things like that, I’m the one that says, ‘hey, we should make an appointment at the dentist’.” Another mother talking about her husband: “It’s not 123 that it occurs to him of ‘I’m going to take my child to the shower, and I’m going to brush his teeth’.” Multiple mothers describe their important role in their children’s oral health: “If the mother doesn’t think about it then it doesn’t happen […] It doesn’t even cross the father’s mind.” A mother with three daughters mentions that her husband is supportive in doing house chores, but his help in oral health is lacking.
In contrast to topics like breastfeeding, playing or screentime, child oral health is rarely discussed with friends and family. A mother argues that oral health might be a “boring topic” and elaborates, “I don’t know why we don’t talk about it unless someone has a pain, a toothache.” A father finds discussing his children’s teeth uncommon during daily conversations because “If his tummy is bothering him, you do start talking about it […] you don’t start talking about, ‘how often do you brush your child’s teeth?’” A mother believes tooth brushing “is something normal” and “nothing new” to discuss. Another mother recognises this, arguing that everybody automatically assumes everyone brushes his or her own teeth. It might even be a “taboo” to talk about bad teeth. On the contrary, a Dutch mother heard from several parents that they hate brushing their children’s teeth.
Parents see limited support from general dental practices as a barrier to taking their children to the dentist. Not all dentists advise that brushing and dental visits from the first tooth are possible. A mother did not know she could bring her young children to the dentist and adds, “I learned something again. Actually, I can bring my baby along too.” Differences in dental policies make it unclear to parents when to register their children. A mother struggling to brush her two-year-old daughter regrets not being informed earlier because her dentist said to bring a child “From one year, so they get used to the environment”. While another mother received the advice: “Dentist really said to me only from four years old.” Sometimes dentists are reluctant to treat young children because they may not cooperate. A father is unhappy about general dentists because “They only look at the money and not the teeth.” An Italian mother adds: “I was actually surprised how little the dentist knew about the young children’s paediatric dentistry, so that was shocking.”
Finally, parents experience too little help from professionals working in general health care, child health clinic, child daycare and preschool or school. A father from Moroccan origin expresses his frustration towards school by saying, “School never talked about the fact of tooth brushing […], but they do talk about nutrition.” Not all parents might know about the potential influence of nutrition, including prolonged breastfeeding (> 12 months) and bottle feeding during the night, on their children’s teeth. A mother who works as a dental hygienist says, “I didn’t know that breastfeeding causes a lot of cavities. I really didn’t know, with my first one, he had so many cavities because he didn’t want to brush properly, but he was also breastfed until two years.” Besides, parents share different stories about the child health clinic. One mother is puzzled because “the child health clinic, they never informed us about dentist or anything either, we really had to figure that all out on our own.” In contrast, other parents indicate that the child health clinic advised them to start brushing from the eruption of the first tooth.
Opportunities and strategies to improve oral health
Parents propose different strategies that could help them to handle their unwilling children and limited support from their surroundings, some of these strategies they already use, others they need to remind themselves of or even wish to receive help with. Parents see opportunities in parenting, family roles, social support, community approach and professional assistance.
Parenting
According to parents, being consequent and setting clear rules is important to limit children’s daily candy intake. A Turkish father argues: “As a parent, you are responsible. You should not buy [candy] or buy less of it.” Another father adds: “If you say ‘yes’ today, then the next day they are going to ask the same […] again, ‘oh, if I do that, then maybe I can get some extra candy […], so you have to stick to the limit yourself.” Parents find explaining to their children how candy may result in cavities or pain is useful. A mother says that her two children ask less for candy because they say, “Sorry mum […] No, my teeth will hurt […] I’m not going to say any more ‘I want more [candy]’.” A mother acknowledges that she needs to be more strict regarding candy but wishes for other alternatives for her child. A father would like more help with what candy does, and he questions: “What’s bad about candy? How much should you take per day? What kind of candy is good?”
To address tooth brushing difficulties, parents agree that perseverance is key. Parents advise to include brushing step-by-step in a daily routine from early on by making it more “fun” and “playful” for young children. Brushing together with siblings and making it part of the sleeping ritual helps to deal with the daily hectic family life. A mother describes how her five children enjoy brushing together. Besides, parents use books, sandglasses, music, toys and songs to make brushing more fun. For instance, a mother buys “toothpaste with nice things on it.” Another mother stresses the importance of explaining to her three children what she does during brushing. A father believes forcing his son is useless, but you should “Stand behind [the child], helping, supporting, listening.” A mother with a Moroccan background strives to “just do my best then […] in terms of brushing my teeth, just no excuses, get up and just do it.” Most parents would like to receive practical tips on how to deal with unwilling children during brushing.
Family roles
Parents mention that it is important to engage with each other to limit their children’s candy intake. Parents propose different strategies to address their discordance in offering candy. Mothers confront their husbands or ensure that candy is not visible to their children. A Moroccan mother mentions: “Dad really loves his candy too. And I always try to hide his bags in a very tall basket in my cupboard.” A father says he and his wife agreed to be strict towards their 1.5-year-old son. Another father admits that he should consider his own behaviour: “Again, no more candy, so that means I can’t buy candy either.” Mothers especially wish for more support from their husbands by sticking to the agreements on food. One father is eager to stop his three-year-old son’s candy intake by buying it once a week but needs help because “You can’t forbid them. That’s impossible.”
Parents believe both father and mother can help deal with unwilling children during tooth brushing. There are households where parents are equally involved in tooth brushing. A mother describes her husband’s role: “When we have a brushing moment, he takes one child, and I take one child, so then we brush together on the sofa.” Fathers also help upon request, and a Moroccan father explains how he encourages his five children: “You have to listen, your mother said ‘go brush your teeth!’ I’m just his mother’s helper, you know.” Some mothers feel that their husbands cannot brush properly. During a community breakfast, a mother mentions that her husband is not allowed to brush her five sons’ teeth because “His brushing is another way of brushing.” A majority of the mothers would be happy to receive more support from their husbands without arguing or bothering them.
Social support
Parents say that having conversations with friends and family is useful in limiting candy. A mother talks about how she confronts her sister to stop giving candy to her son: “You should stop with candy […] there should just be no option.” Sometimes, children are allowed to accept candy from family members, but parents ensure they don’t open it or immediately take it away. Although parents try to engage with grandparents to address their indulgent behaviour, they find it difficult. A Turkish mother struggles to convince her father to consider his behaviour because “I can also hardly go yelling at my father.” Another mother aims to motivate herself and her friends to put grapes and other fruits on the table when they drink tea with the children. Most parents want help in dealing with the embedded need of their social surroundings to provide something sweet to young children.
Parents perceive “social media”, “advertisements”, and “handing out free oral health materials” as valuable to increase awareness of children’s oral health within their community and neighbourhood. Parents learn from each other when they discuss oral health topics at activities organised by local societal organisations. During a communal breakfast with fourteen women, a mother demonstrates how she ensures that her children’s teeth are brushed. Everyone perceives her practical oral health tips as useful. The mothers of the playgroup find it helpful to hear how one mother describes her strategy to brush with her three children collectively: “I sit on the floor and then I do them one by one […] then they lie down, and then I start brushing, and then the next one comes, the next one and so it goes.” Including oral health in existing neighbourhood events is promising to improve attention within the community. For instance, a Moroccan mother talks about handing out toothbrushes and toothpaste at a well-attended neighbourhood fair by families. Parents generally appreciate help through a community approach to establishing healthy oral health habits.
More professional assistance
Parents see opportunities in the current procedures of general dentists. They believe listening to families’ needs and giving advice without judgment contributes to access to dental care. In addition, parents prefer a dental appointment every three months, as illustrated by a mother: “Then I’ve been to the dentist, and it goes well again for a month or two, and then I actually lapse back into the same behaviour again.” Most parents praise the presence of a school dentist. A Moroccan father expresses his preference for a paediatric dentist by saying, “I don’t want to take [them] to a normal dentist either, but rather to the paediatric dentist, because they know better how to deal with children than normal dentists do.” Parents reason that general dentists should be more “friendly” and “patience”, and show “empathy” when treating young children. Most parents need general dentists’ assistance handling their unwilling children during brushing. A mother who regrets that she was not informed to bring her daughter to the dentist mentions: “I think it’s a pity even though I […] make the efforts to brush my daughter, I have to have a professional to guide me a little bit in that.”
Furthermore, parents believe that maternity care, general practitioners, child health clinics, child day care, playgroups, preschools and schools, and the municipality should pay more attention to child oral health. Multiple parents propose ideas for preschools, such as “collective tooth brushing in the morning” or introducing “oral health playfully as a theme” to children. Parents also appreciate the existing food policies of the school as explained by a mother: “Nowadays you are only allowed to bring water or milk […] Biscuits in the afternoon, and things like that are all no longer allowed, so that helps already.” A mother believes the child health clinic could briefly discuss brushing and limited candy. A mother with a Moroccan background agrees: “I think it should actually be included in the check, in the body check of a child, because the eyes are also checked, the ears are checked, and only the teeth are missing.” Parents would like to receive help from professionals outside the dental sector to understand, for instance, when breastfeeding becomes unhealthy for their children’s teeth and other nutritional influences on oral and general health.
Finally, parents say that collaboration between different professionals can be promising. An example is to hire a dentist at preschools and schools to reach families and inform them of the importance of child oral health. A mother explains this:
“It would just be nice if they [preschool] also talked about that, that a dentist really comes by once you know, that kids really grow up with it, that it becomes visible.” A Moroccan father argues, “
Parents, general practitioner, school and dentist, they need to work together.” And a mother adds:
“So maybe those agencies, the childcare, preschool, if we want to tackle it early on, that we should also seek a bit of cooperation there, that the dentists will do a bit in that way, and of course also the education from the child health clinic.”