Parents Perception of Oral Health Problems Present in Photographs of Anterior Teeth

PARENTS’ PERCEPTION OF DENTAL FLUOROSIS AND OTHER ORAL HEALTH PROBLEMS PRESENT IN PHOTOGRAPHS OF ANTERIOR PERMANENT TEETH

C.C. MARTINS,N.B. FEITOSA, M.P. VALE, S.M. PAIVA

Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil

Short Title: Parents’ perception of oral problems

Keywords: Oral Health; Aesthetics, Dental; Dental fluorosis; Malocclusion; Perception; Photography; Tooth Crowding.

Corresponding author:

Carolina Castro Martins

Rua Carangola, 62/101, Santo Antônio

30330-240, Belo Horizonte, MG, Brazil

Phone: + 55 31 32932786, Fax +55 31 3409 2472

E-mail: ,

ABSTRACT

Aim:The aim of this study was to evaluate parents’ perception of dental fluorosis and other oral health problems depicted in photographs of anterior teeth.

Study Designand Methods:The sample comprised 120 parents (average age of 39.3 years) whose children were undergoing treatment at the School of Dentistryof Federal University of Minas Gerais. Seven photographs were selected: (P1) open bite; (P2) dental fluorosis degree TF=1 associated with open bite; (P3) dental fluorosis degree TF=1; (P4) anterior crossbite and crowding; (P5) dental hypoplasia; (P6) dental arcade without oral problems; (P7) dental fluorosis degree TF=3. These photographs were randomly shown to the parents who classified the conditions observed according to a numeric scale: 0-39 (satisfactory), 40-59 (regular) and(60-100) unsatisfactory. The reason for dissatisfaction and the possibletreatment choice was examined.

Results:The photographs showing conditions most frequently classified as unsatisfactory were: P4 (80.0%), P5 (80.0%), P2 (53.3%), P3 (46.7%),P7 (35.8%), P1 (26.7%) and P6 (21.7%). Alignment and crowding were considered by parents the most prevalent problem in all cases (27.5%-90.8%), and the orthodontic treatment was the most frequently cited optionto treat all conditions (34.2%-89.2%).

Conclusions:In general, parents were dissatisfied with the oral conditions depicted in all photographs. The oral problemmost frequently citedby parents was alignment and crowding, and the orthodontic treatment was considered the best treatment option by the majority of parents.

INTRODUCTION

There is a concern whether or not dental fluorosis is a public health problem. Although the prevalence of mottled enamel attributed to dental fluorosis has increased during the last decades, some investigations reported that the mottling is not noticed by most people [Bowen, 2002]. Besides dental fluorosis other oral problems can became a major concernfor parents. The aesthetic perception of teeth condition may differ between patients, dental students and dental professionals[Shulman et al., 2004].

In paediatric dentistry, parents are usually the primary decision-makers on matters affecting their children's health care. Considering parents' central role in ensuring the well-being of their children, it is important to explore their perceptions about children’s' oral health.Parents' assessment about oral health can provide the preventive dental care that children receive at home, the use of professional dental services, the parents’ choice from among several treatment options and also can help in the formulation of dental health policies. Moreover, understanding factors associated with parents' perceptions about children's oral health may help the dental community understand some of the reasons why children do not receive the dental care they need [Talekar et al., 2005].

The aim of this study was to evaluate the perception of parents about dental fluorosis and other oral health problems depicted in photographs of children’s anterior teeth.

MATERIAL AND METHODS

Sample

The sample comprised120 parents (mean age 39.3 years, minimum of 21 years and maximum of 72 years) whose children were undergoing treatment at Orthodontic and Paediatrics Clinic of the School of Dentistryof the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.

The Human Research Ethics Committee of the Federal University of Minas Gerais approved the protocol for this research. The parents agreed to participate in this study by signing an informed consent form.

Photographs selection

Seven images were selected out of the 49 photographs taken in a previous prospective study on dental fluorosis [Martins et al., 2008; Martins et al., 2009]. The children in these photographs were 7 to 9 years-old and lived in two Brazilian cities with optimally fluoridated water (Ibiá, MG and Piracicaba, SP, 0.6 to 0.8 ppm F). The 49 photographs were shown to a team of five dentists who were asked to select the 7 best photographs that represented the following oral problems: open bite; dental hypoplasia, dental fluorosis in mild and moderate degrees, and arcades with two oral problems associated. An arcade without oral problems was selected to serve as control. The most voted photographs by the five dentists were included in the study. If two photographs received the same number of votes, three authors had to decide between them. The photographs are shown in Table 1 (P1-P7). The authors decided to select only seven photographs in order to avoid lengthy interviews that might bore the participants.

The photographs were takenwith lip retractor retractor in place, allowing the viewer to see only the arcade, so that the children could not be identified from the photos. The images were printed in the same laboratory, in 21 x 15 cm size. The sequence of the photographs shown to the parents was randomly organized.

Dental fluorosis images included degrees TF=1 and TF= 3, as defined by Thysltrup and Fejerskov [1978]. Severe degrees with loss of enamelstructure, above degree TF=5, were not included because it is not a common oral health problem of the population of Belo Horizonte, a city with optimally fluoridated public water supply (0.7 ppm F).

Interview

Parents were interviewed in the waiting room of the Paediatric and Orthodontic Clinic by one trained examiner (NBF), while their children were undergoing treatment.The standardisation process was performed by means of meetings with the team of researchers to study the test administration criteria, followed by a pilot study.

The interview included the following questions: the age and educational level of the parent being interviewed and the monthly household income.Theparents were asked to classify the photographs according to a scale varying from 0 to 100. The values determined by the parents were grouped into the following categories: 0 to 39= unsatisfactory; from 40 to 59= regular; and from 60 to 100= satisfactory [Meneghim et al., 2007]. The reason for dissatisfaction was evaluated, with the parents being asked to explain what was the problem with the teeth shown in the photographs. They were also asked if the child on the picture should be treated and which treatment would be appropriate for that particular oral condition.

Pilot study

Prior the main study, a pilot study was carried out in order to provide guidance for the examiner and to evaluate the effectiveness of the interview. Twenty parents out of the study staff were interviewed by the examiner. The interviews were evaluated and the proper corrections and clarifications were made.

Data analysis

Data were entered into the Software Package for Social Sciences (SPSS for Windows, version 12.0, SPSS Inc, Chicago, IL, USA)and a statistical descriptive analysis of the collected data was conducted.

RESULTS

Table 2 shows the demographic features of the study population. The majority of parents interviewed were female (79.2%), with completed middle school (74.2 %) and witha monthly household incomeof less than 2,130.20 GBP(45.0%).

Graph 1 shows the frequency of parents’ satisfaction with the conditions depicted in the photographs of anterior teeth. The photographs depicting conditions that were considered to be the most satisfactory were: P6 (normal arcade, n=78, 65.0%); P1 (open bite, n= 60, 50.0%), P7 (fluorosis TF=3, n= 56, 46.7%).The photographs of conditions mostly frequently classified as unsatisfactory were photographs P4 (anterior crossbite associated with crowding, n= 96, 80.0%) and P5 (dental hypoplasia, n= 96, 80.0%), followed by photographs P2 (fluorosis TF=1 associated with open bite, n= 64, 53.3%) and P3 (fluorosis TF=1, n=56, 46.7%).

Whenasked to explain what was the problem with the teethin the photographs, most parents cited alignment or crowding problems, disregarding whether the teethwere affected or not by these conditions (Table 3). A few parents perceived the teeth as “bigger or wider teeth than those of the primary dentition” and “spaced teeth”. These comments were coded as “shape or spacing” in the Table 1. Parents could perceive staining as an oral problem only on P7 (dental fluorosis degree 3, 50.0%) and P5 (dental hypoplasia, 7.5%). Dental hypoplasia was also perceived as a caries problem by many respondents (30.8%).

More than 84.2% of the parents agreed that all the conditions shown in the photographs needed treatment (Table 3). When asked to explain the appropriate treatment needed by the child in the photograph, most parents (66.7-89.2%) mentioned orthodontic treatment. For photographs 5 and 7 that depicted dental hypoplasia and dental fluorosisdegree 3, respectively, many parents chose cleaning and restorations as treatment options (Table 3).

DISCUSSION

The present study was conducted with parents because they are the primary decision-makers concerning children’s treatment. Datawas collected during an academic semester, involving the total number of patients admitted to the Paediatric and Orthodontic Clinic during one academic semester. This sample can be considered representative of the parents of children undergoing treatment at the School of Dentistry of the Federal University of Minas Gerais.

Photographs were used in the present study because they provide a practical method: they can be shown to a large number of volunteers, ensure patient confidentiality and may restrain the tendency for parents to give their opinions, since the childrenevaluated are not their children.Oral health problems were selected based on the most prevalent aesthetic problems found on anterior teeth of children[Meneghim et al., 2007; Pereira et al., 2009].The malocclusion conditions selected to be shown to the parents were based on dental problems rather than skeletal, because the latter could not be noticed in the teeth photographs alone. Dental caries was not selected as it is not a oralhealth problem commonly found inanterior permanent teeth of 7 to 9 year-old children, and rather affectsthe first permanent molar teeth in children [Batchelor and Sheiham, 2004; Pereira et al., 2009].

The majority of parents (respondents) were female with low educational level and low monthly household income. Except for the parents whose monthly household income was≤ $ 2,840.27 GBP (16.7%) and for those who had completed a college education (11.4%),most of the study population had low socio-economic status. This confirms the homogeneity of the study population.

In 4 out of 7 photographs, the majority of the parents classified the conditions predominantly as unsatisfactory or regular (P2, P3, P4 and P5, Graph 1). When two oral problems were associated [dental fluorosis and open bite (P2) and anterior crossbite and crowding (P4)] the dissatisfaction predominated (53.3% and 80.0%, respectively). Other authors also found that alignment and crowding problems were the main reasons fordissatisfaction [Levy et al., 2005; Menezes et al., 2002; Meneghim et al., 2007].

Dental fluorosis degree 1 was considered to be more unsatisfactory when associated with open bite (P2). Dental fluorosis alone (P3 and P7) had frequencies of dissatisfaction of 46.7% and 35.8%. There is a lack of consensus in the related literature: some studiesreport that dental fluorosis is not cause of concern [Clark and Berkowitz, 1997; Menezes et al., 2002; Shulman et al., 2004;Sigurjóns et al., 2004; Clark et al., 2006, Meneghim et al., 2007],while othersreportthat dental fluorosis was associated to parental dissatisfaction [Lalumandier and Rozier, 1998; McKnight et al., 1998; Lawson et al., 2008]. However when parents were asked to explain what was the problem of the teeth shown in the photograph (Table 3), only dental fluorosis degree 3 (P7) and dental hypoplasia (P5) were related to staining problems (50.0% and 7.5%, respectively). Dental fluorosis degree 1 was not associated to staining. We noticedthat parents misjudged some oral problems, such as dental hypoplasia and dental fluorosis degree 3 shown in Table 3: 30.8% and 4.2% of the parents believed these alterations were dental caries. The same conditions were classified as need of cleaning, restorations and bleaching by parents (Table 4). Results suggest that although parents were dissatisfied with these teeth, they could barely identify the real problem, and that dental fluorosis does not seem to be the major concern of parents. In another study respondents made social judgments based on the aesthetics of the teeth; severe fluorosis or untreated caries were perceived in other studies as unattractiveness, dirtiness and carelessness[Williams et al., 2006]. The lack of information about oral diseases can lead to a poor judgment and poor decisions concerning of the oral healthand affect people’s well-being.

As shown in Table 3, alignment and crowding werethe oral problems most perceived by the majority of the parents, even when the teeth had no occlusal problems. Those parents who referred that the permanent teeth were bigger or wider than those of the primary dentition and that there was some space between teeth, were dichotomized into the variable “shape or spacing”, since it was considered the transition between dentitions. Another study also found that comparisons between the permanent and the primary dentition might have confounded the parents’ perception about the appearance of teeth, e.g. when they cited the more yellow color of permanent teeth cited as a reason for dissatisfaction [Sigurjóns et al., 2004]. Other oral problems were also cited, although they were not present (“gum problems” and “dental caries”).

The majority of the parents agreed that the oral conditions shown in all photographs required treatment (84.2% to 100.0%, Table 4). The desire for treatment did not relate the acceptability of the appearance. In another assessment, in contrast, it was found that the appearance of the teeth considered "acceptable" tended to be classified as having “no needfor treatment”, while the "unacceptable" appearance had been mostly classified as “needingtreatment” [Edwards et al., 2005].

65.0% of parents classified the control image (normal, P6) as satisfactory (the greatest satisfaction among all photographs); however, according to 64.2% of the parents, the teeth had alignment or crowding problems, 84.2% considered the need for treatment, and 71.7% suggestedorthodontic treatment(Tables 3 and 4). Even though there was no oral problem in this arcade, parents considered the need for orthodontic treatment. The same occurred with the other oral conditions shown in the photographs. The findings of the present study are in accordance with similar findings reported in literature about teenagers’ self-perception of their teeth appearance. Although 88.0% of the teenagers foundorthodontic treatment was necessary to improve their own appearance, only 52.0% were identified by dental examination as actually in need for treatment [Marques et al., 2006].Apparently, theparents whose children were undergoing treatmenttended toconsider that every oral condition should be treated. In another study it was found that parents who desired orthodontic treatment for themselves, or who were former orthodontic patients were ten times more likely to approve of orthodontic care in principle and to perceive a need for it in their children. Apart from the effect of parental orthodontic history factors, the results of the investigation confirmed a high level of approval for orthodontic treatment among the parents in general [Pratelli et al., 1998].

In addition to orthodontic treatment, other options frequently cited by parents were bleaching, dental implants and surgery. Many of them meet an increasing demand for aesthetic treatments. Oddly, preventive measures such as cleaning were barely reported. Also, brushing, use of dental floss, annualvisits to the dentist and fluor therapy were not cited. These finding could beextrapolated to other populations. The curative dentistry, focused on complex and invasive methods, was found to be more important for parents than preventive measures, suggesting that more effort should be made to inform the population about the importance of taking preventive measures in oral health, which are inexpensive and can help prevent several diseases.

Nevertheless, the present study has certain limitations. The fact that the children were undergoing dental treatment may also have influenced the parents’ believe that all of the conditions depicted in the photographs needed treatment. Further studies are necessary to evaluate parents’ perception of dental fluorosis and other oral health problems. Also, the evaluation of non-institutionalized people or patients who are not undergoing treatment might have yielded different results.

ConclusionS

Based on the results of this study, it can be concluded that:

- Most of parents considered all oral conditions as unsatisfactory and needing treatment;

- The oral problems most widely perceived by parents were alignment and crowding, and the orthodontic treatment was considered the best treatment option by the majority of parents.

-Data suggest that parents are concerned with other oral problems than dental fluorosis.

ACKNOWLEGMENT

This study was supported by the National Council for Scientific and Technological Development (CNPq).

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