2010 John Wiley & Sons A/S

Community Dent Oral Epidemiol 2011; 39: 260267

All rights reserved

Socioeconomic and clinical

factors associated with
caregivers perceptions of
childrens oral health in Brazil
Piovesan C, Marquezan M, Kramer PF, Bonecker M, Ardenghi TM. Socioeconomic and clinical factors associated with caregivers perceptions of childrens
oral health in Brazil. Community Dent Oral Epidemiol 2011; 39: 260267.
 2010 John Wiley & Sons A S
Abstract Objectives: We assessed how socioeconomic and clinical conditions
could affect parents perceptions of their childs oral health. Methods: A crosssectional study was conducted in a sample of 455 children, aged 15 years,
representative of Santa Maria, a southern city in Brazil. Participants were
randomly selected among children attending a National Day of Childrens
Vaccination. Clinical examinations provided information on the prevalence of
caries, dental trauma, and occlusion. The caregivers perception of childrens
oral health and socioeconomic status were assessed by means of a
questionnaire. A Poisson regression model using robust variance (Prevalence
ratio: PR; 95% CI, P 0.05) was performed to assess the association between the
predictor variables and outcomes. Results: Parents were more likely to rate
their childs oral health as poor if the former earned a lower income and the
latter had anterior open bite and dental caries. Parents of black children with
anterior open bite and dental caries were more likely to rate their childs oral
health as worse than that of other children. Conclusions: Clinical and
socioeconomic characteristics are significantly associated with parents
perceptions of their childs oral health. Understanding the caregivers
perceptions of childrens oral health and the factors affecting this could be
useful in the planning of public health polices, in view of the inequity in the oral
health pattern.

Oral health has been described as an important

feature of well-being. Therefore, abnormalities in
dental conditions play an important role in the way
people perceive their own oral health (1, 2). Over
the last 30 years, the use of sociodental indicators
to measure self-perceived oral health has been
widely advocated (36), because when normative
indicators of oral disease are used alone, they
do not document the full impact of oral disorders
(79).
Evidence suggests that self-rated oral health was
associated with clinical and background conditions
in adults and the elderly (1012). This relationship
has not been well established in preschool children,

260

Chaiana Piovesan1, Macela Marquezan2,

Paulo F. Kramer3, Marcelo Bonecker4 and
Thiago M. Ardenghi5
1
Department of Stomatology, Universidade
Federal de Santa Maria (UFSM), Santa Maria,
RS, Brazil, 2Department of Restorative
Destistry, Universidade Federal de Santa
Maria (UFSM), Santa Maria, RS, Brazil,
3
Department of Paediatric Dentistry,
Universidade Luterana do Brasil, Canoas,
RS, Brazil, 4Departament of Paediatric
Dentistry, Universidade de Sao Paulo, Sao
Paulo, SP, Brazil, 5Department of
Stomatology, Universidade Federal de Santa
Maria (UFSM), Santa Maria, RS, Brazil

Key words: dental services research;

epidemiology; health perceptions
Thiago Machado Ardenghi, Rua
Cel.Niederauer 917 208, Santa Maria, RS
97.015-121, Brazil
Tel.: +55 55 9998 9694
e-mail: thiardenghi@hotmail.com
Submitted 9 June 2010;
accepted 19 November 2010

probably because these children are unable to

complete the questionnaire and provide complete
information. Therefore, the parents are included as
proxies (13).
Parents perceptions of their childs oral health
could influence the oral health decisions and
patterns of health care (14). It has been suggested
that these perceptions could be associated with
clinical and socioeconomic conditions (1517). An
American population-based study found that caries, the perceived need for dental cleaning and
treatment, lower income, and poorer general health
perceptions were associated with poorer parents
perception of their childrens oral health (16).
doi: 10.1111/j.1600-0528.2010.00598.x

Caregivers perception of childs oral health

A theoretical explanation of the link between

socioeconomic status and oral health focuses on the
effect of psychosocial variables on individual lifestyle decisions. This perspective argues that health
inequalities result from differences in the experience of psychological stress between socioeconomic
groups (18), with individuals from lower socioeconomic backgrounds experiencing a higher number
of negative life effects (19), lower levels of social
support (20), and living in communities with higher
levels of antisocial behavior (21). This evidence
supports the indirect model, which proposes that
people experiencing higher levels of psychosocial
stress are more likely to make behavioral or lifestyle
choices that are damaging to health (20). However,
in most developing countries, data on caregivers
perceptions of oral health are scarce. In Brazil,
although previous studies have assessed predictors
for self-rated oral health in adolescents and the
elderly (2224), no study has previously addressed
the caregivers perceptions of childrens oral health.
An understanding of the socioeconomic and
clinical factors associated with caregivers perceptions of childrens oral health could be important
information when planning public health policies,
in view of the inequity in the oral health pattern of
the target population. Therefore, a cross-sectional
study was performed in a representative sample of
1- to 5-year-old Brazilian children, to assess the
influence of socioeconomic and clinical conditions
on caregivers perceptions of childrens oral health.

Methods
Sample
A cross-sectional study was conducted in a representative sample of 1- to 5-year-old children living
in the city of Santa Maria, RS, located in the south of
Brazil. The city has an estimated population of
263 403, including 27 520 children under the age of
6 years. It was estimated that a minimum sample
size of 435 children was required to achieve a level
of precision with a standard error of 5% or less. The
95% confidence interval level and an estimated
prevalence of 50% of the outcome (caregivers poor
perception of childrens oral health) were used to
calculate the sample size. The decision to use a
prevalence of 50% was owing to a lack of information on the actual prevalence of the outcome.
Participants were randomly selected among
the children attending a National Day of Childrens Vaccination. The vaccination program had

consistent uptake rates of over 97% for all the 5- to

59-month-old children living in the city. The age of
the children who participate in the National Day of
Childrens Vaccination ranges from 0 to 59 months.
A sampling quota was selected from all the
children who attended health centers in the city
of Santa Maria. Health centers were used as
sampling points because the city was administratively divided into five regions, and each had
public health centers that were responsible for the
vaccination of the residents in that area. For this
study, eight health centers were cluster selected
from a total of twenty in the city.

Data collection
Data were collected by means of clinical oral examinations and structured interviews. In all, 8 examiners and 24 support team members participated in the
study. They were previously trained and calibrated
for data collection before the survey. During the
survey, every fifth child in the vaccination queue
was invited to participate. If the parents did not wish
to participate, the next parent in the queue was
selected. To avoid a selection bias, siblings were
excluded. This random process was the same at all
the eight health centers. Children were examined in
a dental chair. Their teeth were dried and examined
under standard illumination provided by a conventional operating light. Clinical examinations to
record dental caries, that is, dmft (25); dental trauma
(26); and occlusal patterns were performed.
Data on the socioeconomic status of the target
population were collected by means of a structured
questionnaire. The questionnaire presented a series
of questions regarding socioeconomic and demographic characteristics such as age, sex, mother and
fathers educational levels, race, family income, and
mothers occupation. The educational level compared those fathers and mothers who completed
8 years of formal instruction, which in Brazil corresponds to primary school, with those who only
completed a lower education (<8 years of formal
education). Household income was measured in
terms of the Brazilian minimum wage, a standard
for this type of assessment, which corresponded to
approximately 280 US dollars during the period of
data gathering. Occupational status discriminated
the employed and unemployed parents. The ethnic
groups of the children were assessed according to
their mothers self-report. The survey adopted a
classification of the ethnic groups according to the
criteria established by the agency for demographic
analysis the Brazilian Institute of Geography and

261

Piovesan et al.

Statistics (27). According to these criteria, children

were classified as black (black children of African
and mixed descent) and white (children of European descent).
Data about the parents perceptions of their
childs oral health were measured by the following
questions: (1) Would you say that your childs oral
health is 1 excellent, 2 good, 3 fair, or 4 poor?
[This was dichotomized into good (codes 1 and 2)
and poor oral health (codes 3 and 4).] and (2) How
do you describe your childs oral health? 1 Worse than
that of other children or 2 Better than that of other
children. The feasibility of the questionnaire was
previously assessed in a sample of 20 parents
during the calibration process.

the demographic characteristics of the sample. The

percentage of participating children was similar
across the different age groups. The children were
predominantly white, and their caregivers had a
high level of education. More than half the mothers
were unemployed, with a household income 3
Brazilian minimum wage (BMW). The majority of
the children had adequate sealing lip, and only
34% of the sample had anterior open bite. Prevalence of dental caries and dental trauma were
23.5% and 31.5%, respectively.
Prevalence of the parents who rated their childs
oral health as poor were associated with age,
household income, mothers level of education,

Analyses

Table 1. Sociodemographic and clinical characteristics of

the sample

Data analyses were performed using stata 9.0.

Descriptive and bivariate analyses were conducted
to provide summary statistics and a preliminary
assessment of the association of predictor variables
and outcomes. In the analyses, the following two
outcomes were considered: Prevalence of the parents who rated their childs oral health as poor and
prevalence of the parents who rated their childs
oral health as worse than that of other children.
A Poisson regression model using robust variance (PR; 95% CI, P 0.05) was performed to assess
the association between the predictor variables and
outcomes. A backward stepwise procedure was
used to include or exclude explanatory variables in
the fitting of models. Explanatory variables presenting a P value 0.20 in the assessment of
correlation with each outcome (bivariate analyses)
were included in the fitting of the model. Explanatory variables were selected for the final models
only if they had a P value 0.05 after adjustment.

Ethics
This study observed the international statutes and
national legislation on ethics in research involving
human beings. All the children consented to
participate, and their parents (mothers or fathers)
signed a term of consent. The study protocol was
approved by the Committee of Ethics in Research
of the Federal University of Santa Maria.

Results
A total of 455 children, 53.8% boys and 46.2% girls,
were enrolled in the study. The response rate was
98% of all the invited children. Table 1 summarizes

262

Variable
Sociodemographic characteristics
Childs gender
Male
Female
Childs age (years)
2
3
4
Childs ethnicity
White
Black
Household income
<3 BMW
3 BMW
Mothers schooling
<8 years
8 years
Fathers schooling
<8 years
8 years
Mothers occupation
Unemployed
Employed
Fathers occupation
Unemployed
Employed
Clinical Status
Sealing Lip
Adequate
Inadequate
Anterior Open Bite
No
Yes
Dental caries
dmf = 0
dmf > 0
Dental trauma
Without
With

n*
455
245
210
454
215
120
119
455
345
110
444
203
241
444
129
315
414
122
292
447
240
207
414
32
382
435
342
93
406
268
138
455
348
107
441
302
139

BMW, Brazilian minimum wage.

*Values lower than 455 due missing data.

(%)

53.8
46.2
43.4
26.4
26.2
75.8
24.2
45.7
54.3
29.1
70.9
29.5
70.5
53.7
46.3
7.7
92.2
78.6
21.4
66.0
34.0
76.5
23.5
68.5
31.5

Caregivers perception of childs oral health

presence of anterior open bite, and dental caries

(Table 2). However, in the multiple regression
analyses, only clinical variables and household
income remained associated with the outcome.
Parents were more likely to report their childs oral
health as poor when the former had a low
household income and the latter had anterior open
bite and dental caries.
Table 3 expresses the prevalence of the parents
who rated their childs oral health as worse than
that of other children and the associated factors. In
the final model of the multiple regression analyses,
the parents of black children with anterior open
bite and dental caries were more likely to rate their

childs oral health as worse than that of other

children.

Discussion
The primary purpose of this study is to present
results that could help the dental community
understand the factors associated with parents
perceptions of their childs oral health. According
to previous authors (1517), these perceptions are
influenced by clinical and socioeconomic conditions. It is a well-established fact that people from
low socioeconomic backgrounds are more likely to

Table 2. Prevalence of parents that rated their childs oral health as poor and associated factors
Parents Perception of childs oral health (poor)
Variables

n (%)

Sociodemographic characteristics
Childs gender
Boys
41 (16.7)
Girls
36 (17.2)
Childs age (years)
2
25 (11.7)
3
23 (19.2)
4
29 (24.4)
Childs ethnicity
White
54 (15.7)
Black
23 (20.9)
Household income
3 BMW
28 (11.6)
<3 BMW
46 (22.8)
Mothers schooling
8 years
43 (13.5)
<8 years
32 (25.)
Fathers schooling
8 years
44 (15.1)
<8 years
21 (17.2)
Mothers occupation
Employed
36 (17.5)
Unemployed
39 (16.2)
Fathers occupation
Employed
61 (16.0)
Unemployed
4 (12.5)
Clinical status
Sealing Lip
Adequate
56 (16.4)
Inadequate
18 (19.3)
Anterior Open Bite
Without
38 (14.2)
With
33 (23.9)
Dental caries
Without
38 (10.9)
With
39 (36.8)
Dental Trauma
Without
44 (14.6)
With
30 (21.6)

PRcrude (95% CI)

PRadjusted (95% CI)

1.00
1.02 (0.681.54)

0.89

1.00
1.64 (0.971.76)
2.08 (1.283.39)

0.06
<0.01

1.00
1.33 (0.852.06)

0.20

1.00
1.96 (1.273.01)

<0.01

1.00
1.83 (1.212.75)

0.01

1.00
1.13 (0.701.83)

0.59

1.00
0.92 (0.611.40)

0.73

1.00
0.78 (0.302.01)

0.60

1.00
1.17 (0.721.90)

0.50

1.00
1.68 (1.102.55)

0.01

1.00
1.71 (1.132.59)

0.01

1.00
3.36 (2.274.98)

<0.01

1.00
2.52 (1.673.81)

0.00

1.00
1.47 (0.972.24)

0.06

**

**
1.00
1.84 (1.192.84)

0.01
**

**

BMW, Brazilian minimum wage; n+, number of parents that rated their childs oral health as poor.
**Variables not included in the final multiple model after the adjustment.

263

Piovesan et al.
Table 3. Prevalence of parents that rated their childs oral health as worst than other children and associated factors
Parents Perception of childs oral health (worst than other children)
Variables

n (%)

Sociodemographic characteristics
Childs gender
Boys
12 (5.0)
Girls
8 (3.9)
Childs age (years)
2
6 (2.9)
3
7 (5.9)
4
7 (5.9)
Childs ethnicity
White
8 (2.4)
Black
12 (11.1)
Household income
3 BMW
10 (4.3)
<3 BMW
10 (5.0)
Mothers schooling
8 years
13 (4.2)
<8 years
6 (4.7)
Fathers schooling
8 years
9 (3.2)
<8 years
4 (3.3)
Mothers occupation
Employed
13 (6.4)
Unemployed
6 (2.5)
Fathers occupation
Employed
13 (3.4)
Unemployed
2 (6.4)
Clinical status
Sealing Lip
Adequate
11 (3.3)
Inadequate
8 (8.8)
Anterior Open Bite
Without
7 (2.7)
With
11 (7.8)
Dental caries
Without
7 (2.0)
With
13 (12.1)
Dental Trauma
Without
12 (4.0)
With
7 (5.1)

PRcrude (95% CI)

PRadjusted (95% CI)

1.00
0.77 (0.321.86)

0.57

1.00
2.05 (0.715.98)
2.03 (0.705.93)

0.18
0.19

1.00
4.69 (1.9611.19)

<0.01

1.00
1.17 (0.492.76)

0.71

1.00
1.10 (0.422.85)

0.83

10
1.04 (0.323.32)

0.94

1.00
0.39 (0.151.03)

0.05

1.00
1.85 (0.437.87)

0.40

1.00
2.67 (1.106.46)

0.03

1.00
2.97 (1.177.50)

0.02

1.00
2.76 (1.146.69)

0.02

1.00
5.88 (2.4014.38)

<0.01

1.00
4.39 (1.7610.95)

<0.01

1.00
1.25 (0.503.12)

0.62

**

1.00
3.61 (1.518.66)

0.01

**

**

BMW, Brazilian minimum wage; n+, number of parents that rated their childs oral health as worst than other children.
**Variables not included in the final multiple model after the adjustment.

be exposed to various risk factors that affect the

self-perception of their overall health and wellbeing (2830). For oral health, the same pattern has
been demonstrated (3134). However, most of the
evidence comes from studies conducted on adult or
adolescent populations. Therefore, the aim of this
study was to assess this association in preschool
children, using their parents perceptions as a
proxy. In Brazil, this is the first study that reports
the factors associated with caregivers perceptions
of childrens oral health.
According to Table 2, parents with lower household incomes were more likely to rate their childs
oral health as poor than their counterparts. This

264

confirms the findings that people who have a lower

socioeconomic status were more likely to rate their
oral health as poor, when compared to those who
have a higher status (12, 23). These social disparities remained strongly associated with the outcomes even after the control of other variables.
Previous studies have suggested that socioeconomic inequalities are associated with different
health outcomes (3538). Such inequities could
affect both the childs and familys well-being,
resulting in a negative impact on daily performance and the quality of life owing to the underlying influence of psychosocial, environmental, and
material deprivation (17, 39).

Caregivers perception of childs oral health

It was also found that caregivers perceptions of

childrens oral health were associated with clinical
variables (Table 2). Children with dental caries and
anterior open bite were more likely to have their
oral health rated as poor when compared with
their counterparts.
Our findings confirmed the relationships reported in previous studies between caregivers
perceptions of childrens oral health and dental
caries (15, 16). It has been demonstrated that the
presence of untreated dental caries in the children
is associated with the parents perception that their
childs oral health is poorer, irrespective of their
socioeconomic status (40, 41). For instance, in a
previous study (15), the caregivers perceptions
were significantly associated with the childrens
mean number of cavitated carious lesions. The
authors found that from among those who
reported their childrens oral health status as being
poor, the mean number of untreated cavitated
lesions was approximately 81 times higher than
that of the excellent group (15). Children with
caries cavities are more likely to experience dental
pain and chewing difficulties. They are also more
likely to have been worried or upset about their
oral health status. This may influence the parents
perceptions of their childs oral health (15, 16).
The image of satisfaction expressed by parents
with regard to their child could also explain the
association between anterior open bite and the
outcome (42). Previous investigations suggested
that malocclusion had a significant impact on the
oral healthrelated quality of life (14, 34, 43). The
primary impact of malocclusion on the quality of
life has been reported in the emotional and social
well-being domains, which comprise issues related
to esthetic components. This suggests that the most
significant impact of malocclusion on the quality of
life is because of the psychosocial features rather
than oral or functional problems (34, 44).
The prevalence of the parents who rated their
childs oral health as worse than that of the other
children was associated with ethnic and other
clinical variables (Table 3). Studies with the aim
of assessing the impact of race ethnicity on caregivers perceptions of childrens oral health in
preschool children are scarce. This influence is
complex and appears to be directly related to
biologic, socioeconomic, behavioral, and psychosocial factors (45). The historical exclusion to which
certain groups have been exposed may
explain their predisposition to rate their oral health
as worse than that of their peers. It has been

demonstrated that children from racial ethnic

minorities have higher levels of dental disease
(38). Dietrich et al. (46) found significant racial ethnic disparities in US parents perceptions of the
oral health of their children. They found that the
parents of both Hispanic and non-Hispanic black
children rated their childrens oral health as being
worse-off than that of white children. The results of
the present study are consistent with those of
previous studies that found parents from minority
groups and those with greater poverty levels more
likely to rate their childrens oral health as poor
(16, 47, 48). Findings from previous studies suggest
that there is an association between race and
socioeconomic status. Socioeconomic factors can
interact with social characteristics, such as
race ethnicity, to produce different health effects
across groups (4951). One could argue that the
effect of race on the parents perceptions is dependent on the socioeconomic status. However, the
impact of deprivation on minority ethnic groups
remained strongly associated with the outcome
even after the adjustment for confounders.
Although the role of socioeconomic and clinical
factors on the perceptions of parents with regard to
their childs oral health are important from a public
health perspective, the results presented here must
be considered with caution.
The present study has two primary limitations
that could affect the interpretation of the results.
First, this study followed a cross-sectional design,
which prevents a hypothesis of causality and
temporal relations between the outcome and predictor variables. Studies using a longitudinal
design could provide a better understanding of
the factors influencing the caregivers perceptions
of childrens oral health. Second, one could argue
that the authors did not use a validated questionnaire to measure the childrens oral healthrelated
quality of life (COHRQoL). A few instruments used
for measuring COHRQoL in preschool children,
which include Parental Caregiver Perception, are
presently available (5254). Moreover, no validated
instruments were available for Brazilian preschool
children when the present study was conducted.
However, the lack of information regarding
COHRQoL should not be considered a great bias
of this study, because the primary objective of the
latter was to investigate the predictors for parents
perceptions of their childs oral health using a
feasible instrument that the respondents would
find easy to manage. Furthermore, studies have
shown that the single-item perceived oral health

265

Piovesan et al.

rating is related to other self-reported measures of

oral health, such as multi-item indicators (55).
Thus, a single-item rating of perceived oral health
is particularly appropriate to obtain information
from childrens parents.
The parents perspectives are different from
those of the children. Depending on the type of
information sought in the questionnaire, the
reports of parents tend to be more or less accurate
than those of the children. It has been demonstrated that parents are better able to assess the
areas related to function and physical symptoms
than those related to emotional and social functions
(14). However, very young children are unable to
complete the questionnaire by themselves. Therefore, the use of proxy judgments regarding childrens oral health should be considered a feasible
option to assess the childrens sociodental indicators. Nevertheless, parents maintain accurate
assessments of their childrens oral health status,
which could result in accurate information for the
allocation of resources for dental health services
(16).
This study has resulted in new information from
a clinical and public health perspective. A representative sample of preschool children in Brazil
was used, obtained by a random selection process
at different sample centers around the city. This
random process avoided a bias that might occur if,
for example, the sample were collected in a clinical
setting. Nevertheless, such a process provides
sound conclusions about the research question for
all preschoolers living in Santa Maria.
The present study suggests that parents perceptions of their childs oral health are strongly
influenced by clinical and socioeconomic conditions. Studies on the predictors of these perceptions
are important in health planning by the health
police and the promotion of oral health for the
target population. This is properly described when
considering that clinical measurements of oral
disease have a limited view of the childrens needs
(7, 9). It has been proposed that the planning of a
preventive strategy should take into account the
patients perceptions of needs. The perception of
health may reflect the expectations of oral health
relative to a reference groups. Ethnic and socioeconomic differences may have an important influence
on the parents perceptions of their childs oral
health. The findings that parents from ethnic and
socioeconomic minority groups currently have
more pessimistic views of their childrens oral
health may have important implications on the

266

health policy. Investment in such programs must

include components that determine the perceived
needs of the individuals, rather than a mere
straightforward attempt to combat dental disease.
Therefore, the results presented here, regarding the
caregivers perceptions of childrens oral health,
could be used to assess the needs, prioritize the
care, and evaluate the outcomes of treatment
strategies and initiatives in health care.

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