Background
Dental caries is a global health problem. The prevalence varies across countries [
1‐
4]. Public health initiatives, oral health education and prevention programs have led to a substantial decrease in the prevalence of caries [
5,
6]. Industrialized Western countries have reached the European Goals for Oral Health of the WHO for 2020, which are that children at the age of twelve should have no more than an average of 1.5 DMFT (decayed, missing, filled teeth) [
7,
8]. However, industrialized countries are multicultural migration regions, where children with a migration background usually fail to reach the European Goals for Oral Health, as, for example, in Spain [
9], Italy [
10,
11], Germany [
12], Sweden [
13,
14], Denmark [
15] and Greece [
16]. To improve caries prevention programs, it is important to understand the risk factors for children with a migration background and why they have more caries compared to native-born children.
One of the risk factor for caries development in children is the educational level of parents. Data are available for Stockholm [
17], Palermo [
18], Brussels [
19] and nationwide in Poland [
20] and in Denmark [
21]. Furthermore, the educational level of parents is also a predictor of caries in areas outside of Europe, such as Hong Kong [
22], Brazil [
23] and Iran [
24]. Thus, the educational level of the parents is associated with the oral health of their children. School type is another risk factor for the development of caries in children. For example, in Italy, caries distribution was related to the type of school attended [
25]. In Istanbul, public-school students have been shown to have more caries than children in private schools [
26]. Additionally, type of school has been shown to predict caries status in Brazil [
27] and Jordan [
28]. Overall, the educational level of parents and children’s school type can be considered risk factors for the development of caries.
Twenty-three per cent of Vienna’s population is made up of foreigners, mainly from Eastern Europe. Another major group of immigrants were born in Turkey and in other areas of Asia [
29]. Dental check-ups and treatment for all Austrian citizens are covered by national health insurance [
30]. Does the education level of parents with a migration background therefore have an association with the caries levels of their children? The objective of this study was to evaluate the influence of migration background on the DMFT, including the educational level of parents and their children’s school type.
Discussion
One main finding of this study was that in parents with a higher educational level, migration background and school type have an association with DMFT values. Hitherto unnoticed, in parents with a low educational level, however, migration background and school type have no significant association with DMFT values. These results suggest that children of parents with a migration background are at higher risk of acquiring caries than other children in Vienna, even if parents of the former have a “higher educational level” of apprenticeship training or vocational school education.
The results indicate that children with migration background, attending school in Vienna, would need more support for achieving efficient oral health, even if their parents have received a medium or high educational level. Possible explanations might be the socio-economic status, language barriers, social standing, dietary habits and other factors which were not addressed by this study. The oral health knowledge children receive at school can at least partially compensate for the impact of family oral hygiene. Consequently, in particular children with a migration background, attending school type 2 (level 2C), would benefit from specifically designed oral health care programs.
Our findings are in agreement with epidemiologic studies reporting on the prevalence of caries in school children with migration background in Spain [
9], Italy [
11], Germany [
12], Sweden [
13] and Denmark [
15]. Furthermore, our findings support reports that the educational level of parents is associated with the prevalence of caries in children, although children in the other studies were younger. Most studies only took the educational level of mothers into account [
18,
20,
23]. Interestingly, an increased risk of caries was associated not only with low educational levels of mothers but also even with their high acquisition of university degrees [
36]. We found that even when parents have a higher scholarly education level, migration background has an association with DMFT values. When parents have low educational levels, migration background and school types are not associated with caries. The results can neither be confirmed nor disproved by other studies since comparable studies combining the variables migration background, high and low educational levels of parents and school types of children are not available to our knowledge. However, the results of our study are in line with studies combining migration background and educational levels [
21].
Interestingly, children with migration background in families with highly-educated parents have poorer dental health status than others. Culturally-influenced dietary habits may explain these findings. Living conditions in the country of origin often affect behavior in the country of migration [
37,
38]. This hypothesis is supported by others [
39]. However, those studies also considered the financial background of immigrant families and their length of stay in their new countries One major conclusion of the present study is that even highly-educated immigrant parents need to be informed about the risk of caries development in, and prophylaxis for, their school-aged children.
Together, our findings highlight the need for healthcare programs even for more highly-educated immigrants. Particular interest should also be drawn to special caries prevention programs and dental health education programs. Teeth-brushing programs, educational work, distribution of flyers and lectures on dental hygiene should not be restricted to schools and kindergartens; rather, they should also be provided by religious centers and cultural establishments where parents and children can participate together, in programs [
40]. In addition, regularly-performed dental checkups of all Austrian citizens might help sensitize immigrants and parents with low educational levels to the oral health of their children. Dental checkups, for example, could be provided by the mother-child-pass examination, an Austrian health program. Especially early oral healthcare promotion might improve children’s oral health regardless of their origin [
41]. Parents of native Austrian children with low educational levels might also benefit from such healthcare strategies.
One limiting factor of this study may be that the oral health care of participating children may be better than that of non-participating children. In this study, children and their parents were asked by schools to participate and were nominated for the study when they agreed. Although the participation rate of nominated children was 100%, it is unknown how many children did not agree to participate in the study in advance. Fear of dental examinations or embarrassment over poor teeth may have discouraged participation in the study. Furthermore, owing to one of the main focuses to distinguish between children of parents who have completed compulsory education only, and of parents with a vocational training or higher education, it was not possible to gain the same numbers of participants in all groups. Another bias might be the correlation between school types attended by children and the socio-economic status of their families. We tried to minimize that bias by selecting schools from all of Vienna districts, because life-style is usually a good indication of socio-economic status.
In future studies, the birth countries of immigrant children should be taken into account by comparison the DMFT scores of children still living in the countries and children that were born in the countries, now living in Vienna. Furthermore the knowledge about the children’s original countries could provide more sensitive data, since the prevalence for caries might be different in the countries of origin. In this way one could figure out the group of children with the highest risk and support them and their parents accordingly. It would also be interesting to find out if there is a difference in oral health between children with migration backgrounds born in Austria and those born abroad. Another point of consideration is determination of how long immigrant families have been living in Austria. This would be of particular interest, since in the present study no information is given about current and previous risk of the children, because it was not able to investigate whether the children with migration background, not born in Austria, got caries in Austria or in their home country.
The education of parents, used to measure socio-economic status, reflects the material, intellectual and other resources of their families of origin. Moreover, higher educational levels may make people more receptive to health-education programs [
42]. This is partially in contrast to the findings of this study that children of parents with a migration background are at higher risk of acquiring caries, even if parents have a “higher educational level”. Consequently, in this study, the higher education of the parents do not compensate for the increased caries susceptibility of their children. Therefore, several factors should also be considered to have an influence on the development of caries in children like e.g. genetic and biological factors, social environment, physical environment, health behavior, dental and medical care and time, as described in a conceptual model by Fisher-Owens et al. [
40]. Whether these factors have different influence in children regarding their country of origin cannot be answered with the results of this study, but should be considered in the planning of future studies.
Competing interest
The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.
Authors’ contributions
BC: Analyzed the data, wrote the paper. GHP and PD: Performed the clinical examination. MH: Performed statistical analyses, contributed to review process. RG: Wrote the paper, contributed to discussion. AM and AN: Contributed to discussion. All authors read and approved the final manuscript.