Scoping Review Evaluates Parental Oral Health Literacy’s Influence on Children’s Oral Health Outcomes

The World Health Organization (WHO) has recognized health literacy as a vital health factor in the 21st century. Health literacy, which includes oral health literacy (OHL) as a subcategory, is one of the most fundamental, cost-effective, and long-term strategies for promoting health on a population level. The American Dental Association (ADA) defines OHL as “the degree to which individuals have the capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions.”¹

Previous studies show that individuals with poor health literacy are generally more likely to experience poor health outcomes, have difficulty managing chronic disease, and experience higher rates of illness.¹

To assess this, several tools exist to measure OHL in adults. Most are adapted from medical literacy tests. For example, the Rapid Estimate of Adult Literacy in Medicine (REALM) was modified into a dental version called Rapid Estimate of Adult Literacy in Dentistry (REALD). Another example is the Test of Functional Health Literacy in Adults (ToFHLA) was adapted into a dental version: Test of Functional Health Literacy in Dentistry (ToFHLiD). Despite these existing tools, the critical role of parents in shaping their children’s oral health remains a key area of focus for researchers.¹

Parents play an intricate role in shaping their children’s health and oral health literacy, including their hygiene habits, which significantly contribute to their oral health outcomes. Parents’/caregivers’ OHL involves their ability to recognize and understand their child’s oral health needs, follow preventive oral health practices, seek appropriate oral health care when necessary, and have an advanced knowledge of diet and feeding practices.¹

Parents with limited OHL may lack the knowledge or not prioritize oral hygiene, making it difficult to properly care for their children’s dental needs. As a result, poor oral health habits may be passed down, leading to both immediate and long-term impacts. Therefore, understanding the impact of the level of parents/caregivers OHL on the oral health of their children could be paramount in shaping oral health habits and prevention strategies.¹

The role of OHL in shaping oral health habits among children was examined through a scoping review. A scoping review is a type of literature review that assesses concepts. This review aimed to “review and analyze the relationship between different levels of parental/caregivers’ oral health literacy and the oral health outcomes of their children.”¹

The Review

Conducting a scoping review requires 5 key elements:¹

1. 1. Formulating a research question
   2. Identifying related studies
   3. Selecting relevant research
   4. Organizing data and aggregation
   5. Summarizing and reporting the outcomes

This scoping review aimed to answer the following question: “In pediatric patients, what is the impact of parental/caregivers’ oral health literacy, on the oral health-related outcomes of their offspring?”¹

To answer this question, a search was conducted of 3 electronic databases, PubMed, Science Direct, and Cochrane, and one web-based academic search engine, Google Scholar. The search yielded 2,964 articles published through October 10, 2023. Inclusion criteria consisted of studies on how parents’/caregivers’ oral health literacy affects their children’s oral health, birth to age 17. Only observational and pilot studies published in English were included. Studies that did not provide data on the direct correlation between the parental/caregivers’ OHL and their children’s oral health, research focusing only on adults, or non-original works such as reviews or letters, were excluded.¹

After applying the inclusion and exclusion criteria, 19 studies were identified and included in this review. Most of the included studies were completed in the United States between 2010 and 2023. The studies were evaluated for shortcomings and bias. Shortcomings identified included the absence of non-responder rate data, sample size calculations, and the use of non-representative samples. Most studies had a notable risk of bias. The quality of the studies ranged from low to moderate, with 7 of the 19 considered to be of high quality.¹

The Results

Most of the studies reviewed indicated that children’s oral health was associated with the OHL of the parent/caregiver. This association, identified in most studies, indicated that poor OHL of parents/caregivers negatively affected the oral health outcomes of their children. Unfavorable oral health outcomes included dental caries, inadequate tooth brushing, nighttime bottle feeding, fewer restored dental caries, and infrequent dental visits.¹

Conversely, several studies found a moderate negative correlation between parents’/caregivers’ OHL scores and their children’s dmft scores. However, two of the studies found more nuanced findings. Lower parental OHL did not affect the existence of dental decay but was instead associated with the severity of untreated decay or a reduction in dental service utilization. Another two studies found no correlation at all between parental/caregiver OHL and children’s oral health status, while one study found a correlation between OHL and dental anxiety.¹

Parents/caregivers with higher OHL take their children to the dentist more often. Additionally, higher OHL among parents/caregivers seems to influence their children’s oral health behavior. Unfortunately, the findings indicate that children of parents/caregivers with poor OHL are more likely to suffer from severe dental caries and dental anxiety.¹

Overall, the results of this review highlight the significant role and influence parents/caregivers have on their children’s oral health.¹

Limitations

There is no “gold standard” tool for assessing OHL, so the review identified several issues. First, most tools only assessed a single domain, focusing primarily on pronunciation. The authors found this concerning because there is much more to OHL than simply being able to pronounce oral health-related terminology correctly. Secondly, multiple important domains were excluded, including critical thinking, information-seeking, decision-making, responsibility, and evaluation. The exclusion of these domains was a barrier to assessing the parental/caregivers’ true OHL.¹

This study had multiple limitations. First, a limitation was the inability to report data quantitatively or through meta-analysis due to the diverse assessment tools used in the included studies. Additional limitations include a potential lack of study power and increased risk of bias, specifically selection bias among the studies included in the review. These limitations should be taken into account when interpreting the results.¹

Conclusion

Ultimately, the authors conclude that improving parents/caregivers’ OHL could be an effective strategy to enhance their children’s oral health status and oral hygiene habits.¹

This study, however, only identifies a correlation, not a causal relationship. Though parents/caregivers’ OHL seems to influence their children’s behaviors and oral health, dental disease is multifactorial. Therefore, a single factor is unlikely to cause dental disease.¹

Moreover, health and well-being are shaped not only by personal choices and healthcare access but also by social determinants of health – the conditions in which people live, work, and age. Lower income, education, and minority status are associated with decreased health literacy, which contributes to health disparities. Health literacy can be a stronger predictor of health than socioeconomic or demographic factors. Barriers to dental care exist at multiple levels, including:¹

• • System level: cost and affordability
  • Provider level: negative experiences, language and communication barriers
  • Individual/family level: cultural beliefs, knowledge, and attitudes

Addressing these factors is essential for improving access to dental education and services. The authors suggest that incorporating oral health education in early childhood programs could potentially be an approach to improve parents/caregivers’ OHL. These programs often reach individuals in disadvantaged communities and include culturally sensitive education.¹

Previous studies indicate that parents/caregivers who participate in this type of intervention experience improved access to oral health information, enhanced oral health knowledge, and their children display more positive oral health behaviors, resulting in increased use of preventive dental services. In addition to these educational programs, pediatricians also play a crucial role in improving OHL among parents/caregivers. Pediatricians can advocate for children to have regular dental visits. Unfortunately, although pediatricians have the opportunity to recommend a child’s first dental visit by 12 months of age, a survey in the United States found that 63% of pediatricians only recommended the first dental visit after the child turned 3 years old. This is often due to a lack of sufficient knowledge and awareness about early childhood caries and the necessity for appropriate referrals.¹

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Reference

1. Alzahrani, A.Y., El Meligy, O., Bahdila, D., et al. The Influence of Parental Oral Health Literacy on Children’s Oral Health: A Scoping Review. J Clin Pediatr Dent. 2024; 48(4): 16-25. https://www.jocpd.com/articles/10.22514/jocpd.2024.074/htm