Oral diseases and disorders are common during

childhood and have a negative impact on the life of

young children. However, there is scarce evidence
concerning this impact on their family (1). The
American Academy of Pediatrics denes child
health as the social, physical and emotional func-
tioning of the child and, when indicated, his or her
familytherefore, measurement of health-related
quality of life (QoL) must be from the perspective
of the child and the family (2). In spite of this
existing concept, a limited number of instruments
have been developed to assess family impact. At
present, the FIS (Family Impact Scale) (3) is the only
instrument specically available to determine the
impact of childrens oral and orofacial conditions
on the familys QoL. The psychometric properties
of FIS have been assessed in Canada (3), the United
Kingdom (4), China (5), and Brazil (6). Neverthe-
less, although it has been validated, to the best of
our knowledge, it has not been tested in any
language.
The FIS is an essential component of a child
health-related QoL measure because of the proba-
bility that oral diseases and disorders in a child
could impact the family to some degree and due to
the fact that parents reports of the childs oral
health may be inuenced by the degree to which
the parent is physically or psychologically affected
by the childs condition (3, 7). Moreover, oral care
interventions often address parental needs and
concerns as well as the childs (3, 7). Furthermore,
some studies have also reported that low family
income can have a direct inuence on the responses
concerning QoL (8, 9). The magnitude of this effect
on the parents QoL of children with dental
problems, however, remains unclear.
Community Dent Oral Epidemiol 2012; 40: 323331
All rights reserved
2012 John Wiley & Sons A/S
The impact of dental caries and
trauma in children on family
quality of life
Abanto J, Paiva SM, Raggio DP, Celiberti P, Aldrigui JM, Bo necker M. The impact of
dental caries and trauma in children on family quality of life. Community Dent Oral
Epidemiol 2012; 40: 323331. 2012 John Wiley & Sons A S
Abstract Objectives: To assess the impact of childrens dental caries (DC)
and traumatic dental injuries (TDI) on parents quality of life (QoL), adjusted by
family income. Methods: Parents of 219 children aged 5 and 6 years answered
the Family Impact Scale (FIS) on their perception of QoL and data about income.
Three calibrated dentists examined the severity of DC according to decayed,
missing and lled permanent teeth index, and children were categorized into:
0 = caries free; 15 = low severity; and 6 = high severity. TDI were classied
into uncomplicated and complicated injuries. QoL was measured through FIS
items and total score, and Poisson regression was used to associate the variables
with the outcome. Results: Severity of DC showed a negative impact on the
total score and subscales on parental family activities, parental emotions and
nancial burden (P < 0.001). TDI showed a negative impact on total score and
in some FIS items. The multivariate-adjusted model showed that only the
increase in the severity of childrens DC (RR = 3.19; 95% CI = 2.36, 4.31;
P < 0.001) was associated with a greater negative impact on parents QoL, while
high family income was a protective factor (RR = 0.68; 95% CI = 0.48, 0.95;
P < 0.001). Conclusions: The severity of childrens DC has a negative impact on
parents QoL, whereas TDI do not. A lower family income might have a
negative impact on parents QoL.
Jenny Abanto
1
, Saul Martins Paiva
2
,
Daniela Pro cida Raggio
1
, Paula
Celiberti
1
, Jana na Merli Aldrigui
1
and
Marcelo Bo necker
1
1
Department of Pediatric Dentistry and
Orthodontics, Dental School, University of
Sao Paulo-USP, Sao Paulo, SP, Brazil,
2
Department of Pediatric Dentistry and
Orthodontics, Dental School, Federal
University of Minas Gerais, Belo Horizonte,
MG, Brazil
Key words: oral health; quality
Jenny Abanto, Faculdade de Odontologia de
Sao Paulo, Departamento de
Odontopediatria, Av. Professor Lineu
Prestes, 2227 Cidade Universitaria, CEP:
05508-000, Sao Paulo, SP, Brasil
Tel.: 55(11) 3091 7835
Fax: 55(11) 3091 7854
e-mail: jennyaa@usp.br
Submitted 17 June 2011;
accepted: 4 January 2012
doi: 10.1111/j.1600-0528.2012.00672.x 323
In view of the importance of assessing parents
QoL, the interference of family income in the
perception of QoL, and of the lack of researches
testing the FIS, the purpose of this study was to
assess the impact of childrens dental caries (DC)
and traumatic dental injuries (TDI) on parents QoL
adjusted by family income.
Methods
Prior to its beginning, this study was approved by
the Research Ethics Committee of the School of
Dentistry of the University of Sao Paulo. The
participants legal guardians signed informed con-
sent form.
Study population and data collection
For this cross-sectional study, all children and their
parents, who sought the dental screening of the
Paediatric Dentistry Department, Dental School,
University of Sao Paulo (USP), were initially
eligible (N = 235). Dental screening consists of a
childs oral examination to nd out whether she he
needs a preventive or restorative treatment. All
parents and children were invited to participate in
the study according to the following inclusion
criteria: children aged 56 years, of both genders,
with primary dentition, with no systemic and or
neurological diseases, who had not undergone
dental treatment in the last 3 months, who were
able to be examined intra-orally, and with parents
who were uent in Brazilian Portuguese and were
willing to participate in the study. To avoid
possible biases, relatives and children living in
the same household were excluded from the study.
A total of 219 parents and children were enrolled
during the screening in February 2011 and agreed
to participate in the research (positive response rate
of 93.2%).
On the day of the dental screening, one of the
parents (preferably the one who spent most of the
time with the child) was invited to answer, in a
face-to-face interview, the FIS and a question on
family income. During dental screening, interviews
were carried out by four interviewers who were
blind to the oral examinations. They were trained
in the reading and intonation of each question and
options of responses to the FIS.
Three previously calibrated examiners, all
of them postgraduate students in pediatric den-
tistry, independently carried out the childs oral
examination for DC and TDI. All examiners were
previously trained with pictures of clinical cases for
the studied disorders and diseases. Preceding the
study, the intra-examiner (analysis of examinations
within an interval of 1 week, between each exam-
iner and himself) and inter-examiner reliability was
established using all examiners assessment of 26
children who received dental treatment at the
Dental School of USP. These children did not form
part of the study sample.
Childrens oral examination
The examinations for DC and TDI were performed
in a dental unit using an operating light, a 3-in-1
syringe, tongue depressors, and periodontal
probes.
Dental caries was assessed according to the
World Health Organization criteria (WHO) (10)
and calculated in terms of decayed, indicated for
extraction owing to caries and lled primary teeth
(dmft). No measure of missing teeth is made for the
primary dentition. The dmft was categorized
according to the severity of DC, based on the
previously proposed scores (11): dmft 0 = caries
free; dmft 15 = low severity; or dmft 6 = high
severity.
Types of TDI in anterior upper primary incisors
were classied according to Glendor et al. (12).
Uncomplicated injuries were dened as those in
which the pulpal tissue was not exposed and the
tooth not dislocated (crown fracture of enamel
only, crown fracture of enamel and dentin,
concussion, subluxation). Complicated injuries
involved exposure of the pulpal tissue and or
dislocation of the tooth (complicated crown frac-
ture, root fracture, lateral luxation, extrusive luxa-
tion, intrusive luxation, and avulsion). The child
was considered as having TDI when at least one
kind of trauma was present; otherwise, the child
was considered with absence of TDI (tooth present
and sound).
Family income
The parent was also invited to answer a question
on their monthly family income. Family income
was measured in terms of the Brazilian minimum
wage (BMW), a standard for this type of assess-
ment, which corresponds to approximately US$
320.00 per month.
Family Impact Scale
The FIS is an instrument that evaluates the impact
of a childs oral condition on family life. It was
initially developed by Locker et al. (3) and later
324
Abanto et al.
validated in the Brazilian Portuguese language by
Goursand et al. (6). It consists of 14 items divided
into four subscales: parental family activity (PA),
parental emotions (PE), family conict (FC), and
nancial burden subscale (FB).
The questions refer only to the frequency of
events in the previous 3 months. The items have
ve Likert response options: never = 0, once or
twice = 1, sometimes = 2, often = 3, and every
day or almost every day = 4. The number of dont
know responses was counted, but they were
excluded from the total FIS score for each patient.
The total FIS scores and scores for individual
subscales were calculated as a simple sum of the
response codes. Questionnaires having two or
more unanswered items were excluded from the
analysis.
Data analysis
After a descriptive analysis of the total FIS scores,
the total mean FIS scores and those for the
individual items were analyzed for differences
between DC and TDI. For this initial exploratory
analysis, the KolmogorovSmirnov was used to
assess the normality of the distribution of values.
After this procedure, nonparametric (KruskalWal-
lis) test was used.
Poisson regression analysis with robust vari-
ance was performed to correlate the total mean
FIS score to DC, TDI, and sociodemographic
conditions such as childrens gender and age,
parent interviewed, and family income. This
analysis was performed to exclude variables with
a P-value of >0.20. Explanatory variables were
selected for the nal model only if they had a
P-value of <0.05. In these analyses, the outcome
was employed as a count outcome, as performed
previously (13, 14), and rate ratios (RR) and 95%
condence intervals (95% CI) were calculated. All
variables related to oral health (DC and TDI)
entered and were retained in the nal multivar-
iate model. For all analyses, the statistical soft-
ware STATA 8.0 (Stata Corp, College Station, TX,
USA) was used.
Results
The inter-examiner reliability obtained values of
Cohens kappa agreement of 0.89 for DC and 1.0 for
TDI. For intra-examiner agreement, the examiners
obtained kappa values of 0.92 for DC and 1.0 for
TDI.
All the parents interviewed in this study
(n = 219) completed the FIS, and no questionnaires
were excluded from data analysis because of the
lack of data. Table 1 shows the frequency of
severity of DC and TDI, childrens gender and
age, parent interviewed, and family income.
Most of the questionnaires were answered by
mothers (90.4%). No questionnaire was excluded,
after the analysis of the I dont know responses.
Table 2 displays the distribution of responses to the
FIS according to each item. The items related to the
parents concern about the child having less
opportunities in life, and the feeling of guilt for
childs dental health were the most frequently
reported by parents. Twenty-eight (12.7%) of
the parents reported no impacts, that is, score of 0
(oor effects) on the total FIS (results not shown).
No ceiling effects were observed, that is, score
of 56. The maximum highest score of impacts
reported was 38 on the total FIS of the sample
(results not shown).
Table 3 contains the mean, standard deviation,
median, and the range for the total FIS score and
for each subscale. Table 4 shows the mean differ-
ence between specic oral conditions for each item
and for the total FIS. When the mean total score
Table 1. Sociodemographic characteristics of the sample
(n = 219)
n (%)
DC
Caries free (dmft = 0) 91 (41.6)
Low severity (dmft = 15) 79 (36.1)
High severity (dmft 6) 49 (22.4)
TDI
Absence 140 (63.9)
Uncomplicated injuries 50 (22.8)
Complicated injuries 29 (13.3)
Child age
5 years 130 (59.4)
6 years 89 (40.6)
Child gender
Female 101 (46.1)
Male 118 (53.9)
Parent interviewed
Mother 198 (90.4)
Father 21 (9.6)
Family income (BMW per month)
Up to 1 BMW 28 (12.8)
From 1 to 2 BMW 78 (35.6)
From 2 to 3 BMW 39 (17.8)
More than 3 BMW 45 (20.4)
Dont know 29 (13.2)
BMW, Brazilian minimum wage; DC, dental caries; dmft,
decayed, missing and lled permanent teeth; TDI,
traumatic dental injuries.
325
Family impact related to dental problems in children
was analyzed, it could be observed that the severity
of DC and TDI had a negative impact on the
parents QoL (P < 0.001 and P = 0.004, respec-
tively). Considering each item from subscales,
there was a signicant difference between the
severity of DC and the parents QoL, regarding
the PA, PE, and FB subscales (P < 0.001); TDI
showed a negative impact on the parents QoL only
in items related to less time for themselves, sleep
disrupted, family activities, and be worried for
childrens fewer life opportunities (P < 0.05)
(Table 4).
The univariate analysis considering each oral
condition and sociodemographic factor shows that
the severity of DC, the parent interviewed, and
family income were all correlated with the outcome
variable (P < 0.05) (Table 5). The nal multivariate-
adjusted model comprised three covariates. The
increase in DC severity showed an increased
negative impact on the parents QoL (RR = 3.19;
95% CI = 2.36, 4.31; P < 0.001). Also, a family
income greater than three BMW had a positive
impact on the parents QoL (RR = 0.68; 95%
CI = 0.48, 0.95; P = 0.025) (Table 5). All analysis
presented power values higher than 90%.
Discussion
This study evaluated the impact of childrens DC
and TDI on parents QoL adjusted by family
income. To the best of our knowledge, this is the
Table 2. Parents responses to the FIS (Family Impact Scale) in the survey (n = 219)
Items of the FIS
Never Once twice Sometimes Often Everyday
almost everyday
n (%) n (%) n (%) n (%) n (%)
Parental Family activities (PA)
FIS 1 Have you or the other parent
taken time off work?
152 (69.4) 32 (14.6) 23 (10.5) 12 (5.5) 0 (0.0)
FIS 2 Has your child required more
attention from you or the other
parent?
111 (50.7) 37 (16.9) 30 (13.7) 27 (12.3) 14 (6.4)
FIS 3 Have you or the other parent
had less time for yourselves or other
family members?
167 (76.3) 15 (6.8) 13 (5.9) 18 (8.2) 6 (2.7)
FIS 4 Has your sleep or that of the
other parent been disrupted?
144 (65.8) 26 (11.9) 30 (13.7) 14 (6.4) 5 (2.3)
FIS 5 Have family activities been
interrupted?
179 (81.7) 15 (6.8) 17 (7.8) 3 (1.4) 5 (2.3)
Parental emotions (PE)
FIS 6 Have you or the other parent
been upset?
98 (44.7) 46 (21.0) 50 (22.8) 20 (9.1) 5 (2.3)
FIS 7 Have you or the other parent
felt guilty?
121 (55.3) 27 (12.3) 41 (18.7) 24 (11.0) 6 (2.7)
FIS 8 Have you or the other parent
worried that your child will have
fewer life opportunities?
123 (56.2) 23 (10.5) 27 (12.3) 34 (15.5) 12 (5.5)
FIS 9 Have you felt uncomfortable
in public places?
189 (86.3) 4 (1.8) 18 (8.2) 7 (3.2) 1 (0.5)
Family conict (FC)
FIS 10 Has your child argued with
you or the other parent?
179 (81.7) 10 (4.6) 16 (7.3) 8 (3.7) 6 (2.7)
FIS 11 Has your child been jealous
of you or other family members?
176 (80.4) 7 (3.2) 14 (6.4) 18 (8.2) 4 (1.8)
FIS 12 Has your childs condition
caused disagreement or conict in
the family?
181 (82.6) 15 (6.8) 16 (7.3) 7 (3.2) 0 (0.0)
FIS 13 Has your child blamed you
or the other parent?
197 (90.0) 8 (3.7) 7 (3.2) 4 (1.8) 3 (1.4)
Financial burden (FB)
FIS 14 Has your childs condition
caused nancial difculties for
your family?
164 (74.9) 27 (12.3) 11 (5.0) 15 (6.8) 2 (0.9)
326
Abanto et al.
rst study that has tested one of the versions of FIS
with this purpose after its validation. Moreover, no
studies have assessed the inuence of family
income on parents QoL reports.
The FIS responses reported that items relating to
the parents suggested that the parents had worried
that the child will have fewer life opportunities,
required more attention, and felt guilty because
childs dental health was the most frequent on the
instrument. Considering that only the increase in
childrens DC severity showed a negative impact
on the parents QoL, it is expected that this disease
could promote these emotions in parents due to the
fact that DC severity usually produces an unsightly
appearance, which may concern the parents in
relation to opportunities in the childs future life.
Moreover, it is expected that the child may require
more attention from the parent to relieve discom-
fort resulting from the DC. Although, in the present
study, the researchers did not ask why specically
the parents felt guilty, it could be suggested that
they felt guilty as they fear being blamed for the
problem (15). As the main causes of DC are readily
explained by oral health professionals, parents
know that DC is often related to sweetened food
and poor oral hygiene (16). Furthermore, one study
also reported that parents of preschool children
related to them feel guilty more frequently because
of their childrens DC (1).
The severity of childrens DC and TDI was found
to measurably affect parents QoL in this study
(Table 4). DC showed a negative impact in the PA,
PE, and FB subscales on the FIS. Other studies also
have indicated that DC results in loss of family
activities days or workdays for caregivers who had
to stay home to take care for their child or spent
time and money in accessing dental care (1, 17, 18).
Regarding the PE subscale, the fact that parents
had been upset and felt guilty for their childs
dental health is expected when we think about DC,
for the reasons mentioned earlier. Moreover, the
concept of oral health generally cited by the parents
is when their children do not feel any pain or
discomfort. This may explain the relationship of
upset and guilt with DC severity, where greater
severity causes more pain, which in turn causes
these increased feelings. Abanto et al. (1) also
found a signicant association between parents
Table 3. Mean, standard deviation, median, and range observed in FIS (Family Impact Scale)
Items of the FIS Mean (SD) Median Range observed
Total FIS 8.33 (8.30) 6 038
Parental family activities (PA)
FIS 1 Have you or the other parent taken time
off work?
0.52 (0.89) 0 03
FIS 2 Has your child required more attention
from you or the other parent?
1.07 (1.31) 0 04
FIS 3 Have you or the other parent had less
time for yourselves or other family members?
0.54 (1.09) 0 04
FIS 4 Has your sleep or that of the other parent
been disrupted?
0.68 (1.08) 0 04
FIS 5 Have family activities been interrupted? 0.36 (0.86) 0 04
Parental emotions (PE)
FIS 6 Have you or the other parent been upset? 1.03 (1.12) 1 04
FIS 7 Have you or the other parent felt guilty? 0.94 (1.19) 0 04
FIS 8 Have you or the other parent worried that
your child will have fewer life opportunities?
1.03 (1.33) 0 04
FIS 9 Have you felt uncomfortable in public
places?
0.30 (0.79) 0 04
Family conict (FC)
FIS 10 Has your child argued with you or the
other parent?
0.41 (0.97) 0 04
FIS 11 Has your child been jealous of you or
other family members?
0.48 (1.05) 0 04
FIS 12 Has your childs condition caused
disagreement or conict in the family?
0.31 (0.74) 0 03
FIS 13 Has your child blamed you or the other
parent?
0.21 (0.71) 0 04
Financial burden (FB)
FIS 14 Has your childs condition caused
nancial difculties for your family?
0.47 (0.93) 0 04
327
Family impact related to dental problems in children
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328
Abanto et al.
that had been upset and felt guilty and the severity
of DC in preschool children. One point of concern
in the PE subscale regards the parents felt uncom-
fortable because of their childrens DC in public
places. There are no studies dealing with this
subject; however, we know that parents may feel
bothered with their own children because DC they
present is a relevant result that must be considered
to make the parents aware of the prevention of DC
progression before the appearance of unsightly
lesions that may make them embarrassed. Besides
that, the parents feelings and discomfort concern-
ing their childrens oral health are important for
clinicians, as this may enable them to improve the
childs oral health, thus improving the OHRQoL
of their patients and in consequence the QoL
of parents (1, 19). Therefore, correlation between
family perceptions and childrens oral health can
be important indicators that may impede or facil-
itate childrens use of dental care services (19).
On the other hand, the severity of childrens TDI
showed a negative impact on the total FIS and only
in specic items related to less time for themselves,
disrupted sleep, family activities, and be worried
for childrens fewer life opportunities (Table 4).
Childrens TDI were not negatively associated with
all the FIS subscales compared to DC, probably due
to the fact that most TDI found in the children were
uncomplicated injuries. Nevertheless, complicated
injuries, involving exposure of the pulpal tissue,
can demand more time for the family members
taking care of the childrens symptoms produced
by a severe TDI. It is also expected that the
complicated injuries with dislocation of the tooth
may be a reason for them to get worried about their
childrens fewer life opportunities. One study
shows that only severe levels of TDI produce a
negative impact on schoolchildrens QoL (8); thus,
one would expect a greater impact on parents QoL
when this kind of trauma is present. Still, there is
limited evidence at the present moment about this
association.
Despite the negative impact of childrens TDI in
specic items of the FIS, the nal multivariate
model showed that only the increase in DC severity
produces a negative impact on the parents QoL.
Also, a greater family income in this study had a
positive impact on the parents QoL. This result
conrmed other previous studies which showed
that low family income has a direct inuence on the
responses concerning QoL (1, 8, 9). Socioeconomic
disparities in the OHRQoL in a group of preschool
and schoolchildren were also previously found in
two studies (1, 8). Thus, family income remained a
predictor of children and parents QoL scores after
adjusting for the effects of oral diseases and
Table 5 Univariate analysis and nal multivariate-adjusted model for association between covariates in relation to total
FIS
Covariates
Univariate analysis Multivariate model
Robust RR (95% CI) P-value* Robust RR (95% CI) P-value*
DC
Caries free 1.00 1.00
Low severity 2.12 (1.582.84) <0.001 2.01 (1.512.67) <0.001
High severity 3.51 (2.644.65) <0.001 3.19 (2.364.31) <0.001
TD
Absence 1.00 1.00
Presence 0.86 (0.671.12) 0.268 1.11 (0.881.40) 0.372
Child gender CNS
Female 1.00
Male 1.17 (0.891.54) 0.249
Child age CNS
5 years 1.00
6 years 0.77 (0.581.03) 0.076
Family income (BMW per month)
Up to 1 BMW 1.00 1.00
From 1 to 2 BMW 1.09 (0.791.52) 0.589 1.31 (0.991.72) 0.057
From 2 to 3 BMW 0.67 (0.45 -0.98) 0.040 1.00 (0.681.47) 0.993
More than 3 BMW 0.39 (0.270.57) <0.001 0.68 (0.480.95) 0.025
Dont know 1.07 (0.691.66) 0.756 1.49 (0.992.23) 0.057
DC, dental caries; FIS, Family Impact Scale; Robust RR, robust rate ratio; 1 BMW, Brazilian minimum wage (US$ 320.00);
CNS, covariate not selected for the nal model (P-value > 0.05).
*Calculated by Qui-square test.
329
Family impact related to dental problems in children
disorders. It is, therefore, important to assess
socioeconomic conditions in general when dealing
with health-related QoL research.
Considering that we used a convenience sample
composed of parents who sought preventive
and or restorative treatment for their children, it
could be suggested that they may have a higher FIS
score than those who do not seek dental care
producing an overestimation in our results. There-
fore, we only could extrapolate the results of this
research to the dental ofce setting, where children
are taken prior to receiving treatment. Even though
there are no studies for reference specically
assessing parents QoL, some studies have assessed
the impact of oral conditions on childrens QoL
with convenience samples in hospitals or univer-
sity institutions (1, 2022). Thus, a limitation of this
study is extrapolating the results to the general
population. For that reason, future studies could be
carried out to assess the impact of childrens oral
diseases and disorders on parents QoL in a
representative sample. Considering that the FIS is
a short instrument, its use in epidemiological
surveys is possible, and it can also be included as
indicator of broad use, such as political, research,
public health, and clinical actions.
Conclusion
The severity of childrens DC presents a negative
impact on their parents QoL, whereas TDI do not.
Parents with higher income might report better
QoL, regardless of presence of DC in their children.
Acknowledgements
The authors wish to thank the participants of the Post-
Graduation in Pediatric Dentistry Seminar of FOUSP
for the critical comments put forth. This study was
nancially supported by FAPESP, process no 2009
17040-0.
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