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Parental Perspectives of Early Childhood Caries

Inyang A. Isong, Donna Luff, James M. Perrin, Jonathan P. Winickoff and Man Wai Ng CLIN PEDIATR 2012 51: 77 originally published online 7 September 2011 DOI: 10.1177/0009922811417856 The online version of this article can be found at: http://cpj.sagepub.com/content/51/1/77

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Parental Perspectives of Early Childhood Caries

Inyang A. Isong, MD, MPH, SM1, Donna Luff, PhD2, James M. Perrin, MD1, Jonathan P. Winickoff, MD, MPH1, and Man Wai Ng, DDS, MPH3

Clinical Pediatrics 51(1) 7785 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922811417856 http://cpj.sagepub.com

Abstract Background. Parental perspectives of children with early childhood caries may help inform the development and improvement of caries prevention strategies. Objectives.This study aimed to explore parents experiences, perceptions, and expectations regarding prevention and management of early childhood caries. Methods. The authors conducted semistructured interviews with 25 parents of children aged 2 to 5 years, with a known history of caries. All interviews were transcribed and coded, and iterative analyses were conducted to identify key emergent themes within the data. Results. Parents had limited knowledge of behaviors contributing to early childhood caries and when to first seek regular dental care. Parents expected pediatricians to provide education on how to prevent childhood caries, conduct preliminary oral health assessments, and help establish early linkages between medical and dental care. Conclusion.The findings make a strong case for pediatricians to take responsibility for engaging and educating parents on fostering optimal oral health and helping to access early childhood dental care. Keywords children, parents, caries, qualitative interviews

Introduction
Dental caries is the most prevalent chronic disease in US children, with increasing rates among 2- to 5-year-olds.1,2 It is a reversible disease whose progression or reversal depends on the balance of demineralization and mineralization.3 Although causes of caries are multifactorial, it is primarily a pathologic process driven by bacteria.4,5 However, as with other chronic diseases, various social and behavioral factors influence childrens oral health.6 Childrens diet and oral hygiene practices affect their oral health.7 Optimal prevention and management of early childhood caries (ECC) involves establishment of good oral hygiene, adequate fluoride exposure, and minimized exposure to dietary sugars and refined carbohydrates.8 Families also play an important role in childrens oral health.6 Parents help define oral health practices early in their childs life and also determine when to establish regular dental care. Parental beliefs and self-efficacy help determine to what extent they engage in oral health promoting behaviors. 9 Caregivers oral health literacy is significantly associated with childrens oral disease status.10,11

Until recently, standards of care for ECC called for restorative and surgical treatment, along with general recommendations to change dietary and oral hygiene practices. However, surgical treatment of caries alone does not address the underlying disease process. 12 A contemporary approach to caries disease management is modeled on the medical management of chronic conditions and aims to alter the balance of risk factors in favor of protective factors to halt or slow down the caries process.3 Disease management requires family engagement in day-to-day behavior modifications (tooth brushing, topical fluorides, and dietary control) that address disease etiology.

MassGeneral Hospital for Children, Boston, MA, USA Harvard Pediatric Health Services Research Program, Boston, MA, USA 3 Childrens Hospital Boston, Boston, MA, USA
2

Corresponding Author: Inyang A. Isong, Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, 50 Staniford Street, Suite 901, Boston, MA 02114, USA Email: iisong@partners.org

78 A demonstration project was implemented at Childrens Hospital Boston (CHB) dental clinic to test the feasibility of implementing an ECC disease management approach and determine if this approach would result in improved clinical outcomes. As part of this project, we were interested in qualitatively exploring the prior knowledge, influences and expectations regarding caries prevention and management of parents whose children have ECC. A qualitative approach is useful for developing theoretical insights and allows for a deeper understanding of experiences, perspectives and interactions.13,14 Previous qualitative studies explored parents beliefs, cultural practices, and attitudes toward their childrens oral health.15-18 However, none of these studies focused exclusively on parents of children with prior ECC, while exploring their expectations regarding prevention and management strategies. The aims of this study were to (a) explore how parents perceptions of caries are influenced by their social and physical environment, and health influencing behaviors; (b) explore how parents experiences and perceptions of caries influence ECC management and prevention at home; and (c) determine parents knowledge and expectations regarding prevention and management of ECC.

Clinical Pediatrics 51(1) categories based on clinical indicators of ECC status and clinical outcomes (caries arrest vs progression), age (2-3 years, vs 4-5 years) and race (white, Hispanic, other). We recruited participants from these groups based on the known proportions of the demonstration project population to get a representative sample of respondents. Invitational letters describing the study, including opt-out return post cards, were mailed to a randomized sample of parents of children drawn from each criteria-defined group. We followed up with phone calls to enroll parents who did not opt out.

Data Collection
We conducted semistructured telephone interviews with parents in English and Spanish. English interviews were conducted by IAI (female pediatrician) and Spanish interviews by Odeviz Soto (OS) (male, native speaker, and graduate student). Both interviewers were trained to conduct semistructured interviews. Interviews lasted up to 60 minutes and were conducted using a standardized interview guide. The guide comprised a core list of open-ended questions and probes that were modified iteratively during the interviews to explore emerging themes.21 We developed the guide by adapting questions used in previous qualitative oral health studies17 and in consultation with a team of qualitative research experts (1 cultural anthropologist, 1 sociologist, and 2 clinicians). Questions explored parents general perspectives on health and oral health, knowledge and understanding of caries, and experiences managing their childs caries at home, and receiving dental care on behalf of their child. The interview guide was first translated into Spanish and then reviewed by another Spanish speaker to verify content and meaning. We pilot-tested the guide and obtained verbal consent before each interview. We mailed participants who completed the interview a $45 gift card. We recorded and transcribed all English interviews. We first transcribed Spanish interviews in Spanish and then translated them into English.

Methods
This study was conducted from June to December 2009. To guide the study, we developed a conceptual framework based on the model of Wu et al19 indicating factors (eg, parental beliefs, perspectives on prevention medications, parent/provider interactions) influencing optimal asthma practice by families. We also identified factors from the literature as important in ECC prevention.16,17,20 The study was approved by the CHB Institutional Review Board.

Study Setting/Participants
We recruited parents of children aged 2 to 5 years, with a history of caries, were patients at CHB dental clinic, and had been enrolled in the ECC demonstration project for at least 6 months. The oral health status of many children in the project showed caries arrest (remineralization), whereas other children continued to display caries progression. We used differences in project outcomes (caries arrest or progression), for recruiting equal numbers of parents.

Data Analysis
We used a thematic data analysis approach. Three researchers (DL, MWN, IAI) independently categorized and coded interviews, using NVivo 8. MWN (pediatric dentist) and IAI integrated all coded data. Differences in coding between MWN and IAI were discussed with DLa sociologist experienced in qualitative methods until MWN and IAI reached agreement. The team created a hierarchical structure of codes and higher codes, analyzed the data iteratively, and identified emergent

Sampling and Recruitment Strategy

We used purposive, stratified sampling techniques to identify and recruit parents. Children were stratified into

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Social Milieu Normative pressures Contradictory messages Family Factors Demographics Oral health beliefs Cultural factors Provider/System Factors Provider knowledge Insurance limitations Cost of care Child Factors Overall health Oral hygiene Dietary behaviors Consequences of caries Fluoride exposure Dental visits Optimal Caries Prevention and Management

Parent Factors Oral health beliefs and literacy Attitudes (oral health, fluoride) Oral health experience/expectations Self-efficacy Guilt and perception of blame Competing priorities

Parent/Provider Interaction Communication Parent information seeking Provider counseling strategy

Figure 1. Conceptual model for factors that influence prevention and management of early childhood caries

themes within the data. Qualitative responses did not differ by project outcome group or demographic variables, and so were combined in presentation of results. We integrated key themes and used them to refine our conceptual framework (Figure 1). These major themes are presented in the Results section.

Table 1. Child and Participant Characteristics n (%) Child characteristics Age group (years) 2-3 4-5 Female Insurance status Private Public Public and private Self-pay Parent characteristics Mother Age group (years) 25-29 30-39 40 Race White Black Hispanic Asian Primary language spoken at home not English Other children in household Single-parent household 8 (32) 17 (68) 10 (40) 9 (36) 14 (56) 1 (4) 1 (4) 25 (100) 5 (20) 12 (48) 8 (32) 14 (56) 1 (4) 8 (32) 2 (8) 10 (40) 18 (72) 8 (32)

Results
Of 32 eligible parents to whom we sent letters, 25 (78%) completed telephone interviews (18 English and 7 Spanish). Respondents were all mothers, aged 25 to 59 years (Table 1). Although both parents were recruited, the few fathers preferred to have the interview conducted with the childs mother because they considered the mothers to be the primary care giver. In total, 56% of respondents were white, 32% Hispanic, 8% Asian, and 4% African American.

Thematic Areas Child Oral Health Influences

Impact of lack of knowledge and previous oral health experience. Parents reported that they lacked adequate oral health knowledge and had limited knowledge of behaviors contributing to ECC before participating in the ECC demonstration project. This lack of knowledge was prevalent across all socioeconomic groups, and was perceived by many parents to be an important contributor to their childs ECC. Many felt they were doing everything right and were shocked when their child developed caries. For example, one Spanish-speaking parent was perplexed

by the apparent unclear cause of her childs caries and surmised that he was born with it (Table 2). Parents were not aware of the multifactorial etiology of caries; some

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Table 2. Thematic Area 1: Oral Health Perceptions, Experiences, and Influences

Clinical Pediatrics 51(1)

Impact of lack of knowledge and previous oral health experience Theme 1: Lack of adequate oral health knowledge . . . I am surprised, I dont understand how he ended up with cavities, because . . . he did not use a baby bottle, did not like the pacifier, he only breastfed. And even before his little teeth came out I had already started brushing . . . and I do not know what happens with that. . . . That makes me doubt, because he brought the cavities with him . . . (DT23) Theme 2: Parental surprise at early childhood caries He was about 3. He started experiencing pain and would tell me he has a bad tooth. I didnt really believe him because I didnt think he could get a cavity. So when I first took him to a dentist and they told me that, I was shocked. But it was really pain, pain with sugar or chewing. He had night pain too. (DT16) He was 3 and I made his first dentist appointment and brought him to (the dentist) and they told me he had cavities and that cavities were forming and I almost had a heart attack; . . . I didnt think he would have cavities, it was a shock. (DT13) Theme 3: Impact of parental personal oral health experiences . . . I took (her oral health) very casually until she got these (cavities). My teeth were so good and so were my husbands. . . So we just casually rubbed her teeth with a washcloth every once in a while. Aside from not giving her candy we really didnt worry about it too much until she had a problem. (DT17) I wish that Id taken better care of my teeth. Sometimes I feel like there are things that I take better care of and I realize I kind of project that onto the kids. When I was younger I didnt take the greatest care of my teeth, so I feel like maybe as a parent Im not as good at it. Even though I know its important, every day that Im doing things, there are other things that seem more important. (DT12) Perceived importance of baby teeth Theme 4: Influence of friends and family Well my mother . . . tends to (play) the role of the grandparentso we get a lot of the oh hell be finetheyre just his baby teeth, theyre not his adult teeth, he gets to start over in a few years. Because she doesnt like to see us tell him he cant have something. (DT3) . . . my daughter, shortly after her teeth came in, so probably around 8 or 9 months, I noticed that her front two teeth looked dark to me. My friend assured me oh theyre just her baby teeth, theyre fine. (DT10) Social context/normative pressures Theme 5: Social influences Its difficult for us because we have to tell him often that thats not a snack that is good for his teeth. Thats difficult because there is so much emphasis put on junk food for kids; so much of their social world revolves around birthday parties and snacks, so I feel like often hes being told he cant have something because of that. (DT3) Theme 6: Contradictory messages I figured you know what my kid is drinking milk. I understood there was sugar in strawberry and chocolate syrup, but I didnt realize the risk of the continual milk-filled sippy-cup that youre continually just bathing your teeth in. . . . I mean, we were putting the syrup in (the milk) that was fortified with calcium and they market it saying oh look at this stuff its good for your kid, but on the other hand, its rotting their teeth. (DT7) . . . there was a period of time when he wasnt gaining a lot of weight and we had the nutritionist telling us to get a lot of calories into him but we had Dr X telling us to give him as few snacks as possible. That was really hard. That felt like we were being pulled in two separate directions. (DT3)

had associated it solely with excessive consumption of candy. In addition, most parents were not aware of current recommendations on the timing of the first dental visit. Many reported that prior to their childs ECC experience, they did not feel it was necessary for a child to see a dentist early in life. However, their childs caries experience changed this perception and resulted in them establishing a dental home at age 1 year for subsequent children. Lessons learned from the childs ECC

experience influenced how they managed the oral health of their other children. A key influence on how parents cared for their childrens teeth was their own personal oral health experiences and practices. Some parents reported that they or other family members had experienced tooth problems or dental pain and did not want their children to suffer similar consequences. These experiences altered their perception of their childs ECC and the value they placed

Isong et al. on disease management. They understood the short- and long-term consequences of ECC and wanted to prevent them. The majority of parents valued oral health as important and perceived oral health problems to be as serious as other health problems, with the potential of leading to serious health and social consequences if left untreated. On the other hand, several parents had limited prior experience with ECC and expressed surprise and confusion that young children could experience caries. This lack of knowledge resulted in many disregarding their childs complaint of dental pain and delaying care seeking. Parents own suboptimal oral health practices correlated with negative dental health consequences in their children. Many parents, despite dentist recommendations, reported that they still cared for their childrens teeth the way they cared for their own teeth. Perceived importance of baby teeth. For many families, various erroneous beliefs of friends and other family members played an important role in their childs oral health. For example, the notion that baby teeth are not important was reported by parents as a prevalent belief among family members (especially grandparents) and friends (Table 2). Caries in baby teeth was believed to be temporary, with no long-term consequences. This belief at times resulted in some parents being less vigilant about their childs oral health behaviors or receipt of dental care. Social context/normative pressures. Childrens everyday activities and interactions at school, daycare, birthday parties, and so on, were inundated with unhealthy food choices, which parents found difficult to control. Some parents were reluctant to restrict unhealthy food choices because of not wanting their child to be singled out as being different from other children. Contradictory messages. Parents reported being uninformed about the negative impact some commercial products have on childrens oral health. For example, juice is a product heavily marketed to children and parents, as meeting important nutritional requirements. Not surprisingly, faced with this contradictory message, most struggled to limit their childs juice intake. This struggle also occurred frequently with other marketed products (eg, nonfluoridated toothpaste, multivitamin drinks) marketed as beneficial for children. Parents also noted this tension between their desire to provide what they thought was nutritious or healthy and the need to maintain optimal oral health for their child. A few parents were concerned about exposing their children to fluoride and preferred to use herbal oral hygiene products. The Internet was a commonly cited source of oral health information, especially on natural or herbal products. Parents also relied on friends and family members as sources of information.

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Impact of Early Childhood Caries on the Child and Family

Parents reported various physical, financial, and emotional consequences of caries in their children (Table 3). These consequences affected not just the child but the entire family. Physical consequences of ECC. Physical consequences reported were mostly tooth pain and difficulty eating. Some parents were also concerned about the physical appearance of their childs teeth due to ECC or its treatment. Financial costs. Some families (typically those with private dental insurance) reported excessive out-of-pocket expenses associated with managing their childs caries. Since private dental insurance typically only covers a limited number of preventive procedures per year, high caries risk patients who required more preventive care (eg, more frequent in-office topical fluoride applications) had to pay for the additional treatments out of pocket. In addition, costs associated with frequent dental visits (eg, transportation, parking) as well as payment for dental supplies were burdensome for several families. Emotional effects. Children and parents also suffered emotional consequences of ECC. Some parents reported that their children were embarrassed or had low selfesteem as a result of ECC negatively affecting the aesthetic appearance of their teeth. Some peers teased them, and friends and family members often made comments about their tooth discolorations or missing teeth. Parental perceptions of blame and feelings of guilt. Many parents believed that their childs ECC was perceived by health care clinicians as a parenting failure. Several parents felt guilty or responsible for their childs caries. A few parents reported first perceiving blame from a care provider, which then led to subsequent feelings of shame and guilt. Feelings of guilt were also associated with incidences of pain, aesthetic concerns, or need for general anesthesia for their childs dental work.

Parental Information Seeking and Expectations of Pediatricians

Parents recognized that all caregivers (parents, dentists, pediatricians, teachers, daycare providers) played a role in preventing ECC. They especially looked to their childs pediatrician as an important source of oral health information but often felt that this information was not provided. Because children have frequent interactions with pediatricians, parents turned to them first for oral health information and advice regarding ECC prevention,

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Table 3. Thematic Area 2: Impact of Early Childhood Caries on the Child and Family

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Theme 7: Physical consequences of early childhood caries . . . When he wants to eat, he cant eat hard things like a normal kid who has good teeth . . . I have to cut up meat for him, he cannot chew well and I think that affects his daily life as a child, because its not enough to break up the little pieces of meat for him, or to break up the things that he cannot eat well; he needs his good little teeth; . . . now he complains that a molar hurts him, a little molar, so, he doesnt want to eat, I had to take him to the doctor again . . . (DT22) Theme 8: Costs It definitely is a big ordeal. . . . we added up how much we were paying just for fluoride and visits and it was $28 a month, $300 for the stuff that we pay per year plus those two cavities that were filledthats $400. So it adds up! And then we were trying to weigh that against the cost of just having them (the cavities) fixed in the OR. (DT8) Theme 9: Emotional effects Kids would just say such mean things to her, like you dont brush your teeth, your mouth is nasty . . . just horrible. I noticed that she just wouldnt smile. And if she did smile she would always put her head sideways so she didnt have to look directly into the camera. (DT4) Theme 10: Parental perceptions of blame The dentist was very ignorant; she made me feel like I was a dead beat mother. It was kind of like why did you wait till he was 3? I had no idea. I didnt know that he had to go when they first had their teeth. I didnt know any of that. I didnt go to the dentist when I was a kid, he was my first kid, and she kind of just looked at me when I have my history and the fathers dental history like, why would you even bring a kid into this worldtype attitude and I didnt even want to deal with her. (DT13) I dont know if it was my own like, self-projected . . ., but I dont think so. Almost like they didnt believe me what I was feeding her, or that I . . . I felt like they thought it was my faultthat I didnt take good care of my daughters teeth. (DT10) Theme 11: Parental feelings of guilt . . . You try to do everything possible for your kids and then youre told hes got these (cavities) You dont want to put your child under general anesthesia unless its absolutely necessary so it was really a bad experience and I felt like it was all my fault. (DT9) I felt kind of bad, like I failed at making his teeth healthy and was giving him all the wrong things. I thought they were good for him but I guess I was wrong. (DT15)

or when they noticed early signs of caries (eg, tooth staining, or white spot lesions indicating demineralization). A few parents were satisfied with the pediatricians appropriate provision of preventive dental care and timely dental referral. However, most parents reported receiving erroneous or no oral health information (Table 4). Some parents were frustrated by the pediatricians failure to provide education on ECC prevention, conduct preliminary oral health assessments, and recommend or help them establish early linkages between medical and dental homes.

Discussion
This study provides a unique view of childrens oral health from the perspective of parents of children who have caries. As has been previously reported, the social milieu within which children live, including family and social factors, played an important role in ECC prevention and management.6 These social influences and normative pressures impacted parents ability to optimize their childs oral health. A new finding of this study was the effect of contradictory messages on childrens oral health. These findings emphasize the importance

of addressing the social context in ECC prevention programs, and ensuring accurate information in consumer marketing. Consistent with prior studies,10,11 parents limited oral health literacy was important in ECC prevention. Parents reliance on personal oral health experiences to guide their care of their childs teeth contributed to many children experiencing ECC and delayed care seeking. In a study by Horton and Barker,16 parents misdiagnosed their childs caries as tooth stains in need of cleaning, and delayed care seeking until the child developed tooth pain. Various strategies have been implemented to improve parents oral health literacy. One regulatory approach recently implemented in Massachusetts requires child care programs to assist children with tooth brushing. The goal is to provide families with oral health information and increase awareness of the importance of good oral health practices for children. Additional targeted oral health education efforts could be delivered through Women, Infants and Children programs, prenatal classes and maternal postpartum hospital discharge counseling. Many consequences of ECC described in this study have been documented previously.22-25 The perception of feeling blamed by health care clinicians for their childs

Isong et al.
Table 4. Thematic Area 3: Parental Information Seeking and Expectations of Pediatricians

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Theme 12: Erroneous or inadequate oral health information I did speak to the pediatrician around 2 (years) and said Im really concerned about his teeth I dont think hes getting a good brushing. . . . his comment to me was do the best you can. I thought I was doing the best I can. So I said when do I start taking him to the dentist? and he said wait till about 3 (years). I even asked my own dentist and she said well, when can he sit in a chair. So I said hes very active and she said well then just wait. So I felt like I was looking for advice and got bad advice . . . (DT16) I noticed that her teeth were not normal like the other childrens. Then I told the pediatrician, and the pediatrician did not pay attention. . . . she did not help me out. She told me she did not know the reason for it, and that she could not help me because she was too young to be sent to the dentist. (DT25) Theme 13: Parental expectations of pediatricians I was actually kind of angry with his pediatrician because I felt like if she had lifted his lips and looked and examined his teeth at 1 year she might have seen something that could have been addressed like 6 months earlier. Thats my opinionI think they should have done a little check of the teeth at that time. (DT9) I noticed, that his teeth started coming out quite early . . . they started turning a little bit yellow; and I would say, maybe its the toothpaste I am using. I would tell the pediatrician and she would tell me that everything was fine, and everyday, they were turning more and more yellow . . . I would tell her to refer me to someone (I did not know I could go to the dentist without her reference), and she would not refer . . . I told her that my sons teeth were looking badly, she did not seem to take me seriously. (DT24)

caries expressed by several parents in this study was a novel finding. Our report of parental guilt was documented previously in another qualitative study, where parents expressed guilt as a result of being unable to prevent ECC or extensive dental treatment for their children.26 A key finding of this study was that parents value pediatricians as an important source of oral health information but most reported receiving no or incorrect information from them. In a study by Hilton et al,17 when parents were asked which health provider they would choose to conduct their childs oral health assessments at 1 year, most said they would choose the childs primary care provider. However, only 54% of pediatricians conduct oral health examinations and counseling for more than half of their patients, largely because of a lack of oral health training.27 Various initiatives have been implemented to enhance oral health training among medical students, residents, and practicing pediatricians. The federal government, through the Title VII program, has encouraged and funded the development of collaborative and interdisciplinary training in oral health between medicine and dentistry.28 Several medical schools and residency programs have implemented oral health internships and training modules.29-30 Our study highlighted important influences on childrens oral health that could be addressed in clinical practice. Training programs could equip medical and dental providers to address many of these factors, for example, the broader social context, low oral health literacy, perceptions of guilt and blame, and consequences of poor oral health on the family. Providers can be trained to incorporate core concepts of family-centered care in

delivering preventive dental care, avoid a blaming approach and provide counseling in a sensitive, nonjudgmental way. Additional strategies can also be implemented to foster consistent, accurate messaging, and integrate oral health into overall systems of care so that pediatricians are better equipped to provide family-centered oral health information and services to their patients. This study has several limitations. One limitation of qualitative research is the possible introduction of investigator bias during collection and analysis of data.31 Differences between both interviewers (gender, interview style), could have influenced data collection. We attempted to limit these qualitative research biases by using a standardized interview guide, triangulating our findings, and drawing on the expertise of a multidisciplinary research team in coding and analyzing data. Our results represent the perceptions of a small group of parents attending a dental clinic in Boston. Because of their enrollment in the ECC demonstration project and experience caring for their children with caries, parents may have knowledge and insights that do not apply to other groups. Focusing on parents of children with caries lends unique and contextual insight into childrens oral health influences from a parental perspective, and can help clinicians better understand how to meet the needs of families of children at risk for caries. Our findings confirmed some of the important domains identified in our conceptu al framework, and also enabled us to refine the framework to include newly identified factors (eg, perceptions of blame) that influence prevention and management of ECC (Figure 1). Future studies can assess if factors

84 identified in this exploratory study are generalizable to larger populations. A better understanding of pathways that influence childrens oral health could inform the design of new approaches to ECC prevention and management in young children.

Clinical Pediatrics 51(1)

tooth decay: pilot study at a migrant farm workers clinic. ASDC J Dent Child. 1992;59:376-383. 8. American Academy of Pediatrics. Oral health risk assessment timing and establishment of the dental home. AAP Policy Statement. Pediatrics. 2003;111:1113-1116. 9. Finlayson TL, Siefert K, Ismail AI, Delva J, Sohn W. Reliability and validity of brief measures of oral health-related knowledge, fatalism, and self-efficacy in mothers of African American children. Pediatr Dent. 2005;27:422-428. 10. Vann WF Jr, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: impact on oral health outcomes in early childhood. J Dent Res. 2010;89:1395-1400. 11. Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on childrens oral health outcomes. Pediatrics. 2010;126:107-114. 12. Barton DH. Clinical outcomes for early childhood caries. J Dent Child (Chic). 2004;71:188. 13. Murray SA, Kendall M, Carduff E, et al. Use of serial qualitative interviews to understand patients evolving experiences and needs. BMJ. 2009;339:b3702. 14. Giacomini MK, Cook DJ. Users guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence-Based Medicine Working Group. JAMA. 2000;284:478-482. 15. Wong D, Perez-Spiess S, Julliard K. Attitudes of Chinese parents toward the oral health of their children with caries: a qualitative study. Pediatr Dent. 2005;27:505-512. 16. Horton S, Barker JC. Rural Mexican immigrant parents interpretation of childrens dental symptoms and decisions to seek treatment. Community Dent Health. 2009;26:216-221. 17. Hilton IV, Stephen S, Barker JC, Weintraub JA. Cultural factors and childrens oral health care: a qualitative study of carers of young children. Community Dent Oral Epidemiol. 2007;35:429-438. 18. Hoeft KS, Masterson EE, Barker JC. Mexican American mothers initiation and understanding of home oral hygiene for young children. Pediatr Dent. 2009;31:395-404. 19. Wu AC, Smith L, Bokhour B, Hohman KH, Lieu TA. Racial/ethnic variation in parent perceptions of asthma. Ambul Pediatr. 2008;8:89-97. 20. Butani Y, Weintraub JA, Barker JC. Oral health-related cultural beliefs for four racial/ethnic groups: assessment of the literature. BMC Oral Health. 2008;8:26. 21. Pandit NR. The creation of theory: a recent application of the grounded theory method. The Qualitative Rep. 1996;2(4):1-20. 22. Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E. Beyond the dmft: the human and economic cost of early childhood caries. J Am Dent Assoc. 2009;140:650-657. 23. Siegal MD, Yeager MS, Davis AM. Oral health status and access to dental care for Ohio Head Start children. Pediatr Dent. 2004;26:519-525.

Conclusion
Parents reported significant physical, emotional, and economic impacts of ECC on the child and family. Various family and social influences impact parents ability to provide optimal oral health for their children. Parents have inadequate knowledge about preventing caries in their young children and value pediatricians as an important source of oral health information. Early clinical opportunities exist to engage and educate parents as partners in optimizing childrens oral health and hygiene in order to improve oral health outcomes. Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by DentaQuest Institute. Dr Isongs work is supported by a National Research Service Award (T32 HP10018) from the Health Resources and Services Administra tion, Department of Health and Human Services. We thank Odeviz Soto (OS), Gay Torresyap and Dr. Peter Maramaldi for support and contributions to the study.

References
1. Carmona RH. National call to action to promote oral health. J Am Coll Dent. 2005;72(4):8-10. 2. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11. 2007;(248):1-92. 3. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131:887-899. 4. Seow WK, Clifford H, Battistutta D, Morawska A, Holcombe T. Case-control study of early childhood caries in Australia. Caries Res. 2009;43:25-35. 5. Berkowitz R. Etiology of nursing caries: a microbiologic perspective. J Public Health Dent. 1996;56:51-54. 6. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on childrens oral health: a conceptual model. Pediatrics. 2007;120:e510-e520. 7. Weinstein P, Domoto P, Wohlers K, Koday M. MexicanAmerican parents with children at risk for baby bottle

Isong et al.
24. Tickle M, Blinkhorn AS, Milsom KM. The occurrence of dental pain and extractions over a 3-year period in a cohort of children aged 3-6 years. J Public Health Dent. 2008;68:63-69. 25. Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ, Judd P. Malnourishment in a population of young children with severe early childhood caries. Pediatr Dent. 2006;28: 254-259. 26. Mofidi M, Zeldin LP, Rozier RG. Oral health of Early Head Start children: a qualitative study of staff, parents, and pregnant women. Am J Public Health. 2009;99:245-251. 27. Lewis CW, Boulter S, Keels MA, et al. Oral health and pediatricians: results of a national survey. Acad Pediatr. 2009;9:457-461.

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28. Ng MW, Glassman P, Crall J. The impact of Title VII on general and pediatric dental education and training. Acad Med. 2008;83:1039-1048. 29. Mouradian WE, Reeves A, Kim S, et al. A new oral health elective for medical students at the University of Washington. Teach Learn Med. 2006;18:336-342. 30. Silk H, OGrady Stille S, Baldor R, Joseph E. Implementation of STFMs Smiles for Life oral health curriculum in a medical school interclerkship. Fam Med. 2009;41: 487-491. 2009. 31. Giacomini MK, Cook DJ. Users guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 2000;284:357-362.