Original Article

Increasing the Awareness of the Parents Regarding the Oral Health Status of Their 0-3 Years-Old Children


  • Tamer TÜZÜNER
  • İlknur KAHRİMAN
  • Özgül BAYGIN
  • Ezgi BALTACI
  • Ayca KURT

Received Date: 19.01.2021 Accepted Date: 10.05.2021 Bezmialem Science 2022;10(3):337-345


This study aimed to: (a) compare nursing students’ knowledge about the oral and dental health of children before and after oral health education; (b) evaluate the effectiveness of oral health education of parents with children aged 0-3-year-old by these trained students during home visits.


In this quasiexperimental study, firstly, 60 senior students in the nursing department were trained on infants’ and young children’s oral and dental health through standartized training modules. Secondly, 180 parents with children aged 0-3 from low socioeconomic status were trained by the nursing students during home visits with face to face interviews. Both nursing students’ and parents’ pre and post-training knowledge levels and the changes in their awareness after training were measured using standard questions which were administered as pre-test (preT) and post-test (postT) with 1 week intervals. Wilcoxon test was used to assess the differences of correct answers between pre- and post-tests. The significant value was considered as p<0.05.


The mean age of the children of the parents was 18.92±9.96 months. The median values of preT and postT were found to be 28 and 37.5, respectively for the total number of correct answers given to 50 questions related to the education consisting of seven modules. It was determined that the total number of correct answers increased statistically significantly in postT (p<0.001). The median values of preT and postT correct answers to 14 questions in the education given to parents through brochures were found to be 6 and 10, respectively. It was determined that the total number of correct answers increased statistically significantly in postT after the training (p<0.001).


The knowledge level of nursing students about the oral and dental health of children can be increased through standardized training programs. Home visits and face-to-face interviews are applicable to increase awareness in parents by non-dental healthcare professionals.

Keywords: Oral health, awareness, health education, home visits, nursing students


The oral and dental health of children is essential for general body health and healthy adulthood (1). Considered as a whole, oral health in childhood includes topics related to nutritional and cleaning behaviors, first dentist appointment, tooth cavities, preventive treatments, non-nutritive sucking habits, changes in the jaws and teeth during growth and development, mouth injuries, and other oral diseases (2,3). Early childhood caries (ECC) is defined as the presence of one or more decayed tooth (cavitated or non-cavitated lesions), missing tooth due to caries, or filled surfaces in the primary teeth of children younger than 6 years of age, and any sign of smooth surface caries in children younger than three years is an indicator of severe ECC (S-ECC) (4). According to a study carried out in 2015 (5); caries observed in primary teeth affected 560 million children worldwide and became the 12th most common disease when examined together at all ages. The high prevalence of ECC in children aged 1, 2, and 3, which is 17%, 36%, and 43%, respectively, indicates that this disease is left untreated in children under 3 years of age (6,7). The treatment process of ECC requires sedation/general anesthesia methods with high costs and potential health risks due to the cooperation difficulties of the age group it affects, and the recurrence of lesions is frequently observed after the procedures, thus creating a social and economic burden (8-10).  Dental injuries are the most common ones of oral injuries, and luxation injuries are the most common injuries in children aged 1-3 years and usually caused by falls (11,12). Oral injuries are often perceived as a neglected public health problem due to the inability to access appropriate healthcare at the right time (13). The untreated early oral and dental diseases observed in children cause eating difficulties, pain complaints, increase in the risk of infection, growth and development problems, sleeping difficulty, restricted social life, increase in absenteeism at school, behavioral problems, and decrease in the quality of life of the child and family (14-16).

The biological, behavioral, psychosocial characteristics and awareness and knowledge levels of those responsible for the primary care of the child (mostly the mother) are the main factors that have a role in the maintenance of oral and dental health of children (17). In developing countries, social and economic inequalities, insufficient dental care centers and staff, non-dental health professionals who do not have enough equipment in the oral and dental health of children, and inability to integrate oral health into the primary health care system cause preventable oral and dental health problems in children to continue to be relevant and to increase (18,19).

The 0-3 age period is an important time period for parents to have awareness of oral and dental health in children and receive guidance for the development of correct attitudes and behaviors (20). Nurses are among the first healthcare professionals that the family and child encounter in the healthcare system for reasons such as home visits, routine controls, information, vaccination, and childhood diseases. This situation provides an important advantage to this occupational group in terms of informing parents about oral and dental health in children (21,22).

This study aims to educate senior nursing students about oral and dental health in neonatal and childhood periods and to raise awareness of parents with children aged 0-3 about the oral and dental health of children by means of face-to-face interviews and brochures through these nursing students during home visits. Our hypotheses are;

1. After the education to be given to nursing students, awareness and knowledge levels can be increased,

2. With the nursing students and the brochures prepared, the awareness and knowledge level of the parents can be increased after the education.


Ethical Consideration

The study was approved by the Karadeniz Technical University Committee on Human Research (approval number: 2015/42). Before ethical approval, permission was obtained through correspondence with Georgetown University for use of their courses via online access and the tests prepared in international standards to measure the effectiveness of the education that were available back in 2016 under the title “A Health Professional’s Guide to Pediatric Oral Health Management”. Although the educational content at the website was no longer available, the training modules were provided as a child oral health resource for healthcare providers previously (23). All the documents regarding permission, original and/or Turkish versions of training modules, tests and previous presentations are available at the web address of http://tamertuzuner.com/0_3_yas_cocugu_bulunan_ebeveyn_egitimi.zip.

Necessary legal permissions were also obtained from the Republic of Turkey Ministry of Health and Public Health Institution for home visits and field activities involving parental education. Informed written consent was obtained from both nursing students and parents that participated in the study.

Subjects and Sample Size

The study was conducted in Trabzon, Turkey with 180 parents with children aged 0-3 years old who lived in City Center, and 60 senior nursing students studying in Karadeniz Technical University, Faculty of Health Sciences, Class of 2017. Parents selection were made from low socioeconomic status (monthly income below TRY 1770) (24).

Since the number of possible nursing students that could be included to the study population were obtained as 60, we included the whole students into the study design who signed the consent form. Thus, we decided to achieve the final calculation by considering the total number of parents. After considering alpha error =0.05, beta error =0.20 and the effect size as 0.20, the required parent numbers were determined as 164. However, by considering the possible dropouts, missing data, and failures for the study design, we determined to use 180 (averaged 10% increased) parents. Thus, one nurse was matched with 3 parents to complete study design.

Study Design

In this study, pretest-posttest model, one of the quasi-experimental research designs, was used (Table 1). The translation process for educational content and questions asked to both nurses and parents was carried out in two stages. In the first part, the original English version was translated into Turkish separately by a professional interpreter and a pediatric dentist with a good command of English who was not a participant in the study, and a draft was created by combining the Turkish versions. In the second part, the Turkish draft version was answered by 10 nursing students and parents who were not included in the study, and points in the drafts that could not be understood were evaluated and edited. The test-retest (internal consistency) of the answers were also tested between 1 week intervals by nursing students and parents who were not included in the study with final Turkish version. The final Turkish version was translated into English by a professional interpreter and compared with the original one (Table 2). As a result of compliance and internal consistency, all questions were used in the study.

The research was carried out in two stages. In the first stage, 60 senior nursing students were given theoretical and practical education with a training guide which included such topics as; an introduction to infants and young children’s oral health, oral conditions and abnormalities, prevention of oral diseases, non-nutritive sucking habits, oral injury, infants and young children with special health care needs and the relationship between general health and oral health, by faculty members from the department of pediatric dentistry, department of pediatric nursing and department of public health nursing. The training content was documented to facilitate the follow-up of the courses by nursing students and to ensure their use later.  A survey with 50 questions (Table 3) was applied to nursing students as a pretest before the training to measure the level of knowledge, awareness, and demographic variables. The questionnaire to measure the level of knowledge of the modules at the beginning of the study were re-administered as a posttest one week later and recorded.

In the second stage, some of the survey questions (relatively important topics) applied to nursing students were designed for parents as a survey of 14 questions (Table 4) by faculty members from the department of pediatric dentistry, and applied to parents as a pre-test. Previously trained senior nursing students visited selected families for oral health education with brochures, dental toothbrushes, and models. Home-visits were conducted under supervision of faculty members of Faculty of Health Sciences. The families were visited again one week after training and the same questionnaire to measure level of knowledge and awareness was repeated as a post-test. The results were analyzed to evaluate the success of training.

Statistical Analysis

The data were analyzed with SPSS for Windows 17.0. Descriptive statistics of demographic data were recorded for both nursing students and parents. The distributions of the correct answers to the questionnaires were also calculated with descriptive statistics. The Cronbach alpha level was calculated for test-retest activity. Compliance with normal distribution was evaluated by Shapiro-Wilk test. The Wilcoxon test was used to assess the differences of the correct answers given by students and the parents between one-week intervals. The confidence interval was determined as 95% in all methods.


Demographic information of nursing students and parents who participated in the questionnaire was given in Table 5. It was found that nursing students were mostly female, and the majority of the parents were mothers. The educational level of the parents in the research group was found to be generally primary and secondary education levels. The mean age of the children in the study was 18.92±9.96 months. The Cronbach alpha levels were found higher than >0.70 both for nursing students and parents.

Considering the findings of oral health education for nursing students; who were educated through standardizes training modules and whose knowledge/awareness levels were evaluated with pretest/posttest methods (50 questions), it was determined that the number of correct answers were higher than the pretest in the posttest (p<0.001) except for the module 5, and even an increase was found in all subheadings (p>0.05) (Table 6).

As a result of 14-question pretest/posttest of brochure-based information given to parents about the oral and dental health of their 0-3 year-old children within the scope of home visits, it was found that awareness levels increased significantly (p<0.001) (Table 7).


In this study with quasi-experimental design, the increase in knowledge and awareness of 60 senior nursing students through standardized training programs and 180 parents with children aged 0-3 years, who were educated by these nurses through home visits, about oral and dental health in children was investigated and all hypotheses were proven to be right.

As far as we know, there was no study through which non-dental health professionals performed a practice in the field in order to raise awareness of parents with children at such young ages in our country. Social and behavioral factors such as the parents’ level of education and income, family’s level of knowledge of the oral health including the feeding and cleaning habits, the number of children in the family, and the environmental conditions the child lives in are observed among the risk factors for early childhood oral and dental health (26,27).
Preventive oral and dental health services in children primarily aim to reach the parent responsible for the primary care of the child and to increase knowledge and awareness on this issue (28). This study was initiated by foreseeing that it would be beneficial that nurses took an active role in preventive oral and dental health guidance services for parents following the experiences they would gain by expanding their curriculum.

The necessity of integration of oral and dental health as a part of general health with primary healthcare services is an issue that has been studied in many studies globally (29-31). In the prevention of ECC, as well as general practitioners and pediatricians, with whom family and child meet before the dentist in the health system, nurses, too, have an advantageous position in terms of information, early diagnosis, and anticipatory guidance (32). This kind of integration concept requires a complex structure and should be approached from different perspectives. Common barriers to integration are observed as the absence of appropriate health policies and the lack of education of non-dental health professionals in oral health (33). In a study conducted in Turkey, (25) it was presented that pediatric nurses had insufficient knowledge of oral and dental health in newborns and children.

In 1986, the American Academy of Pediatric Dentistry recommended that children’s first dentist visit should be performed before the age of 1 (34). In our country, the first encounter of a child with the dentist occurs if the oral and dental problems catch the attention of the parents or when these problems progress enough to affect the daily life of the child. The insufficient number of pediatric dentists, the unwillingness of general dental practitioners to care for pediatric patients, and the difficulty experienced by families in accessing an institution providing service for the dental health of their children due to geographical and socioeconomic barriers are among the factors that require the scope of general health services to be changed in preventing ECC. In the report published by the Organization for Economic Cooperation and Development and the European Union (EU), it is stated that due to the income levels, geographical conditions, and the limitations of the health system of 28 member countries of the EU, the unmet oral health needs are disadvantageous to the low-income group, according to the data of 2014 (35). There are studies presenting the prevalence of S-ECC as 51% (36), %78.57 (37), and %61 (38) in Turkey. Considering that these studies were performed on patients presented to dental clinics of universities in developed cities in Turkey, it could be projected that the number of children without access to dental health services across the country was much more. According to Petersen and Kwan (39), the population living in cities has higher rates of access to oral and dental health services compared to those living in rural areas in all income brackets.

Parents who participated in the study were of low socioeconomic status and their educational levels were mostly primary and secondary according to the data of the local Family Health Center. Considering the effect of social inequality on access to dental services, the selection of the sample group was both a strong feature of the study and a risk of bias.  For the same reason, the fact that the method chosen to raise awareness in parents was through home visits and face-to-face interviews was among the factors that increased the effectiveness of the study in overcoming cultural and geographical barriers, but partially carried the risk of bias. Home visits are comprehended as a promising approach to the implementation of preventive health services for psychosocially and economically disadvantaged families (40,41). Accordingly, in our study, awareness was decided to be created through home visits.

The training modules used in the study were not only related to ECC, but also included the issues such as anomalies that could be observed in the oral cavity, prevention of oral diseases, non-nutritive sucking habits, oral injuries, and the relationship between oral health and general health. English-Turkish and Turkish-English translations of these training modules were performed and standardized by different people who were competent in their fields. Quasi-experimental research designs test causal hypotheses and  analyse changes in outcomes before and after an intervention (42). The effectiveness of these standardized training modules was evaluated by pre/post-testing on both nursing students and parents.  The increase in the levels of knowledge and awareness of nursing students and parents educated by these students about the oral and dental health of children at the end of the tests indicated that these standard training modules were effective.  Consequently, we foresee that applying the comprehensive education model in the study to larger populations in the future may be beneficial.

Study Limitations

There were some limitations in the study. Quasi-experimental methods are most often used when it is not possible to randomize individuals or groups to treatment and control groups (42). The lack of randomization in the nursing students and parent groups and the limited number of samples, the fact that there was no long-term test results and motivation follow-up of these groups, and the inability to determine the long-term effect of parent education on the oral health of the child due to the lack of registration and oral examination of the children of the parents who were educated were the limitations of the study. We think that these issues should be taken into consideration in future studies to be conducted on this subject. Home care practices are not a new concept for health legislation in Turkey (43). However, there is a need for more studies by considering the multidisciplinary approach in the process of creating appropriate health policies and their integration into primary health care services.


As a result of this study, which could be considered as a pilot study, it was foreseen that; The knowledge level of nurses about the oral and dental health of children could be increased through standardized training programs. Home visits and face-to-face interviews performed in order to raise awareness in parents were applicable within the scope of preventive dentistry in children.  The non-dental primary care providers could be used in increasing the knowledge and awareness of parents about the oral and dental health of children.


Ethics Committee Approval: The study was approved by the Karadeniz Technical University Committee on Human Research (approval number: 2015/42).

Informed Consent: Informed written consent was obtained from both nursing students and parents that participated in the study.

Peer-review: Externally peer reviewd.

Authorship Contributions

Concept: T.T., H.K.M., İ.K.,  Design: T.T., Ö.B., Data Collection or Processing: T.T., H.K.M., İ.K., A.K.,  Analysis or Interpretation: T.T., H.K.M., Ö.B., E.B., A.K.,  Literature Search: T.T., H.K.M., Ö.B., E.B., A.K.,   Writing: T.T., E.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: This study was supported financially by the Scientific and Technological Research Council of Turkey (TUBITAK-3001; project number: 315S060).

  1. Newacheck PW, Hughes DC, Hung Y-Y, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000;105(Supplement 3):989-97.
  2. Ling HTB, Sum FHKMH, Zhang L, Yeung CPW, Li KY, Wong HM, et al. The association between nutritive, non-nutritive sucking habits and primary dental occlusion. BMC Oral Health 2018;18:145.
  3. Tinanoff N, Baez RJ, Diaz Guillory C, Donly KJ, Feldens CA, McGrath C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. International journal of paediatric dentistry. 2019;29:238-48.
  4. Dentistry AAoP. Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies. 2016 AAPD Reference Manual. 2018.
  5. Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. The lancet 2016;388:1545-602.
  6. Kassebaum N, Bernabé E, Dahiya M, Bhandari B, Murray C, Marcenes W. Global burden of untreated caries: a systematic review and metaregression. J Dent Res 2015;94:650-8.
  7. Phantumvanit P, Makino Y, Ogawa H, Rugg‐Gunn A, Moynihan P, Petersen PE, et al. WHO global consultation on public health intervention against early childhood caries. Community Dent Oral Epidemiol 2018;46:280-7.
  8. Meier T, Deumelandt P, Christen O, Stangl G, Riedel K, Langer M. Global burden of sugar-related dental diseases in 168 countries and corresponding health care costs. J Dent Res  2017;96:845-54.
  9. Sinner B, Becke K, Engelhard K. General anaesthetics and the developing brain: an overview. Anaesthesia 2014;69:1009-22.
  10. Amin M, Nouri R, ElSalhy M, Shah P, Azarpazhooh A. Caries recurrence after treatment under general anaesthesia for early childhood caries: a retrospective cohort study. Eur Arch Paediatr Dent 2015;16:325-31.
  11. Bhutia DP, Singh G, Mohammed S, Ram H, Gamit J, Howlader D. Prevalence and etiology of pediatric maxillofacial injuries: a unicenter-based retrospective study. Int J Clin Pediatr Dent  2019;12:528.
  12. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth: John Wiley & Sons; 2018.
  13. Inoue N. Oral injuries in children presenting to a Japanese pediatric emergency room. Pediatr Int 2017;59:826-30.
  14. Chaffee BW, Rodrigues PH, Kramer PF, Vítolo MR, Feldens CA. Oral health‐related quality‐of‐life scores differ by socioeconomic status and caries experience. Community Dent Oral Epidemiol 2017;45:216-24.
  15. Perazzo MF, Gomes MC, Neves ÉT, Martins CC, Paiva SM, Costa EMdB, et al. Oral problems and quality of life of preschool children: self‐reports of children and perception of parents/caregivers. Eur J Oral Sci 2017;125:272-9.
  16. Piva F, Pereira JT, Luz PB, Hugo FN, de Araújo FB. Caries progression as a risk factor for increase in the negative impact on OHRQOL—a longitudinal study. Clin Oral Investig 2018;22:819-28.
  17. Phillips M, Masterson E, Sabbah W. Association between child caries and maternal health-related behaviours. Community Dent Health 2016;33:133-7.
  18. Douglass JM, Clark MB. Integrating oral health into overall health care to prevent early childhood caries: need, evidence, and solutions. Pediatr Dent 2015;37:266-74.
  19. Caries EC. IAPD Bangkok Declaration. Int J Paediatr Dent 2019;29:384-6.
  20. Ismail A, Razak IA, Ab-Murat N. The impact of anticipatory guidance on early childhood caries: a quasi-experimental study. BMC Oral Health. 2018;18:126.
  21. Khanbodaghi A, Natto ZS, Forero M, Loo CY. Effectiveness of interprofessional oral health program for pediatric nurse practitioner students at Northeastern University, United States. BMC Oral Health. 2019;19:170.
  22. Cooper D, Kim J, Duderstadt K, Stewart R, Lin B, Alkon A. Interprofessional oral health education improves knowledge, confidence, and practice for pediatric healthcare providers. Front Public Health 2017;5:209.
  23. Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. Front Public Health .ront Public Health 2009;21:1-10.
  24. Aslan G. The Number of Minimum Wage Workers and the Change in Wage Levels (2003-2017 Household Labor Force Surveys Data Analysis). SGD-Sosyal Güvenlik Dergisi 2019;9:141-59.
  25. Kahriman İ, Karadeniz H, Tüzüner T, Kuşgöz A. An evaluation of the knowledge of pediatric nurses about the oral health status of newborns and pediatric oral health care. Clinical Nursing Studies 2017;5:53-8.
  26. Dabawala S, Suprabha BS, Shenoy R, Rao A, Shah N. Parenting style and oral health practices in early childhood caries: a case–control study. Int J Paediatr Dent 2017;27:135-44.
  27. Li Y, Wulaerhan J, Liu Y, Abudureyimu A, Zhao J. Prevalence of severe early childhood caries and associated socioeconomic and behavioral factors in Xinjiang, China: a cross-sectional study. BMC Oral Health 2017;17:144.
  28. Anil S, Anand PS. Early childhood caries: prevalence, risk factors, and prevention. Front Pediatr 2017;5:157.
  29. Atchison KA, Rozier RG, Weintraub JA. Integration of Oral Health and Primary Care: Communication, Coordination and Referral. NAM Perspectives 2018;1-12.
  30. Maxey HL, Weaver DL. Oral health and primary care: exploring integration models and their implications for dental hygiene practice. EBH 2016;3:196-202.
  31. Harnagea H, Lamothe L, Couturier Y, Esfandiari S, Voyer R, Charbonneau A, et al. From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care. BMC Oral Health 2018;18:23.
  32. Bhagat V, Hoang H, Crocombe LA, Goldberg LR. Incorporating oral health care education in undergraduate nursing curricula-a systematic review. BMC Nursing. 2020;19:1-13.
  33. Harnagea H, Couturier Y, Shrivastava R, Girard F, Lamothe L, Bedos CP, et al. Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open 2017;7:016078.
  34. Dentistry AAoP. Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies. 2016 AAPD Reference Manual. 2018.
  35. Auraaen A, Fujisawa R, De Lagasnerie G, Paris V. How OECD health systems define the range of good and services to be financed collectively. 2016.
  36. Ozler CO, Tekcicek MU, Ozdemir P, Dogan BG, Ozsin Ozler C, Uzamis Tekcicek M. Pufa Index and Related Factors Among 36-to 71-month-old Children in Turkey: A Cross-Sectional Study. Oral Health Prev Dent 2018;16:467-72.
  37. Kaya M, Mandaci SM, Kargül B. Risk Factors for Early Childood Caries: A crosssectional study in a Dental School. Bezmialem Science 2018;6:272-9.
  38. Özen B, Van Strijp A, Özer L, Olmus H, Genc A, Cehreli SB. Evaluation of possible associated factors for early childhood caries and severe early childhood caries: A multicenter cross-sectional survey. J Clin Pediatr Dent 2016;40:118-23.
  39. Petersen PE, Kwan S. Equity, social determinants and public health programmes–the case of oral health. Community Dent Oral Epidemiol 2011;39:481-7.
  40. Haber J, Hartnett E, Hille A, Cipollina J. Promoting Oral Health for Mothers and Children: A Nurse Home Visitor Education Program. Pediatric Nursing 2020;46:70-6.
  41. Jungmann T, Brand T, Dähne V, Herrmann P, Günay H, Sandner M, et al. Comprehensive evaluation of the pro kind home visiting program: A summary of results. Mental Health & Prevention 2015;3:89-97.
  42. White H, Sabarwal S. Quasi-experimental design and methods. Methodological briefs: impact evaluation 2014;8:1-16.
  43. Çelik Güzel E, Toprak D. Home-Care Services In Turkey. Klinik Tıp Aile Hekimliği Dergisi 2018;10:15-9.