AWARENESS OF CHILD ORAL HEALTH AMONG PARENTS AND CAREGIVERS ATTENDING PEDIATRICS OPD AT BPKIHS, DHARAN

of the child. To assess awareness of child oral health among parents and caregivers aending Pediatrics OPD at Dharan. A cross-seconal quesonnaire-based study was conducted among conveniently selected 400 parents and caregivers of six months-to-14-year-old children aending Pediatrics OPD, BPKIHS, Dharan. A single interviewer administered pre-tested standardized quesonnaires to the parcipants. The quesonnaires consisted of ﬁve domains: sociodemographic proﬁle of the parcipants; child's oral hygiene pracces; child's feeding and dietary habits; awareness of child's ﬁrst dental visit and presence of family dental problems; and child's dental service ulizaon. Data were entered in MS excel 2007 and stascally analyzed using SPSS version 11.5. Data analysis included descripve stascs. Majority (90%) of the and caregivers were literate and 44.3% belonged to the lower-class socioeconomic status. parcipants that took a and 77.6% 91% the respondents reported the age of the ﬁrst be any when there was a The of the presence of oral health problems in their child seen in 29.5%, where as 18% had made previous dental visits. Despite the fact that most parents and reported factors aﬀecng their oral evidence a lack awareness and, as a result, low ulizaon of dental services for their children. ABSTRACT


Introduc on
Parents and caregivers are the key sources responsible for their children's good health. They are the basic needsprovider and role models as well for their children to learn good oral habits early on. Thus, their awareness about the factors affec ng child oral health is an essen al component for the well-being of the child.

Objec ves
To assess awareness of child oral health among parents and caregivers a ending Pediatrics OPD at BPKIHS, Dharan.

Methodology
A cross-sec onal ques onnaire-based study was conducted among conveniently selected 400 parents and caregivers of six months-to-14-year-old children a ending Pediatrics OPD, BPKIHS, Dharan. A single interviewer administered pre-tested standardized ques onnaires to the par cipants. The ques onnaires consisted of five domains: sociodemographic profile of the par cipants; child's oral hygiene prac ces; child's feeding and dietary habits; awareness of child's first dental visit and presence of family dental problems; and child's dental service u liza on. Data were entered in MS excel 2007 and sta s cally analyzed using SPSS version 11.5. Data analysis included descrip ve sta s cs.

Result
Majority (90%) of the parents and caregivers were literate and 44.3% belonged to the lower-class socioeconomic status. 83.3% of the par cipants reported that their children took a sugary diet and 77.6% of them brushed once daily before breakfast. 91% of the respondents reported the age of the child's first dental visit to be any age when there was a dental problem. The awareness of the presence of oral health problems in their child was seen in 29.5%, where as 18% had made previous dental visits.

Conclusion
Despite the fact that most parents and caregivers reported factors affec ng their children's oral health, there was evidence of a lack of awareness and, as a result, low u liza on of dental services for their children. 1,2 The oral health of children is integral to their general health. Parents and caregivers are the primary sources responsible [3][4][5] for their children's good oral and overall health. Apart from their educa on level and socioeconomic situa on, the parents' and caregivers' awareness, a tudes, and prac ces [6][7][8][9][10][11][12][13] regarding oral health influence the child's oral health. Dental caries is the most frequent oral ailment majority of 14 the children have. In fact, mothers are known to be the first 15 to infect their children with cariogenic bacteria and therefore, high levels of it in the mothers increase the likelihood of developing dental caries in their children by 11 16 mes. The consequences of early childhood caries follow high risk for caries development throughout the life me, frequent emergency landings and hospitaliza ons apart from the regular school missings, increased me and cost of treatment, and overall slumped oral health-related quality 17 of life. Amongst the various factors associated with caries development in children, feeding and dietary habits 18,19 especially with regard to sugar consump on , oral 20 21 hygiene prac ces , and u liza on of dental services are of prime concern.

INTRODUCTION
In developing countries like Nepal, most dental visits are 22-made only when severe pain and disability ensue. 24 Dispari es between oral and general health priori es amidst the commoners have been the pre-eminent problem faced by the dental professionals in establishing a standard oral care regime especially for the children. Considering that most of the oral problems are largely preventable, focusing on preven ve methods for child oral health takes the utmost 25 priority. Thus, raising awareness on child oral health among the parents and caregivers and making dental care accessible to them through various government, community, and local approaches is the need of the hour. Integrated oral and primary care approaches reinforcing dental referrals for children in early ages, preferably by their first birthday is 2 6 , 2 7 highly recommended. Therefore, the study was conducted among the parents and caregivers a ending pediatrics OPD to assess their awareness of child oral health and mo vate and reinforce them accordingly for regular u liza on of dental services to improve child's oral health.

METHODOLOGY
This cross-sec onal ques onnaire-based study was conducted from 2012-2013 a er obtaining Ins tu onal Review Commi ee clearance and informed consent from the par cipants. Based on the convenient sampling, 400 parents and caregivers of the children aged six months to 14 years a ending Pediatrics OPD, BPKIHS, Dharan were 28 selected. Only children aged six months and above were included as six months being the recommended me for the 26,27 first dental visit of child. Parents and caregivers of the non-ambulatory children and those unwilling to take part in the study were excluded. A personal interview of the par cipants was carried out using pre-tested standardized ques onnaire by a single interviewer. The ques onnaire consisted of five domains: Domain 1 included a sociodemographic profile of the parents and caregivers (educa on and socioeconomic status); Domain 2 included five ques ons on child's oral hygiene prac ces; Domain 3 included ten ques ons on child's feeding and dietary habits; Domain 4 included four ques ons on awareness of the child's first dental visit and presence of family dental problems and Domain 5 included three ques ons on child's dental service u liza on. Data were entered in MS excel 2007 and sta s cally analyzed using SPSS version 11.5. Data analysis included descrip ve sta s cs.

RESULTS
In this study, about 90% of the par cipants were literate and 44.3% belonged to the lower-class socioeconomic strata (Table 1). Table 2 shows the response to oral hygiene habits of the par cipants' children. Out of the 400 par cipants, 281 (70.3%) reported that their children cleaned their mouth while 119 (29.8%) did not. Among those who cleaned their mouth, more than half (62.3%) reported regular cleaning whilst the two-thirds (77.6%) cleaned only once before breakfast. Most of them (96%) used brush and toothpaste for cleaning and 90.3% used fluoridated toothpaste. Table 3 shows the responses of par cipants on the feeding habits of their children. In this study, the majority (80%) of the par cipants reported to have breas ed their child, while 19% of them had both breast-and bo le-feeding prac ces. Breas eeding was seen most commonly for a dura on of one-to-two years (34.3%) and bo le-feeding for a dura on of 0.5 to one year (32.5%). More than half of the parents and caregivers (67.5%) reported of bo le-feeding sweetened milk to their children and in 49.4% of the children, bo lefeeding even during the night-me was observed. Out of the 400 par cipants, 298 (74.5%) reported that their children were weaned at less than six months of age, while 102 (25.5%) children were weaned at six or more months of age.       Table 4 shows responses of the par cipants on child's dietary habits related to sweet intake. The habit of sweet intake was seen in 83.3% of the children, with 58.9% occurring between meals and at least twice a day for the 123. Out of the 400 children, 128 (32%) had regular medicated syrup intake. Table 5 presents responses of the par cipants' awareness of the child's first dental visit and the presence of dental decay in their family. The major (91%) response to the age of the first dental visit of a child was "Any age whenever problem arises" while only 2.8% replied as soon as the tooth erupted or by the first year of age. More than a quarter (29.5%) of the parents or caregivers were aware of their children having some oral health problems. 34% of the par cipants reported that the child's siblings also had dental caries and less than half (39.5%) self-reported the presence of decay in their mouth. 82% of the respondents had never had a previous dental visit. Among those who had made a dental visit (18%), more than half (67.6%) responded having had their last visit more than 6 months back of which dental pain (32.4%) was found to be the most common reason. (Table 6

DISCUSSION
Dental caries is the most common oral disease for people of 29 all ages. Despite studies showing a global decline in dental caries, its prevalence in Nepalese children has risen [30][31][32] drama cally in the last 20 years.
This mul factorial disease begins with the erup on of a tooth in a child's mouth when cariogenic bacteria are transmi ed primarily from mothers (ver cal) and through horizontal channels (from siblings or in child care centers) par cularly during 33 certain infec vity periods. Because caries is a preventable disease and parents and caregivers are the primary sources of oral health care for children, their understanding of factors impac ng their children's oral health is closely linked to their child's oral health throughout childhood and into adult hood.The findings of the study showed most of the parents and caregivers reported the presence of factors affec ng child oral health implying a lack of awareness and, as a result, poor usage of dental services for their children. This study also a empted to increase awareness of the child oral health among the parents and caregivers a ending Pediatrics OPD with a discussion on the importance of child oral health and their first dental visit for each.
According to studies, caries occurrence is lower in children whose parents or caregivers are educated and have a solid [10][11][12][13] financial situa on. Because 90% of the par cipants in this study were literate, acquiring oral hygiene rou nes was rather simple. However, over half of the par cipants (44.3%) were from lower socioeconomic backgrounds, which may make it difficult for them and their children to access dental care on a regular basis. Children prac cing good oral hygiene habits such as brushing twice a day using fluoridated 20 toothpaste decrease their caries risk. This study showed that more than half (62.3%) of the children cleaned their mouths regularly using a brush and toothpaste (96.1%), with fluoridated toothpaste (90.3%). However, two-third of the children cleaned their mouths only once before breakfast (77.6%) which might be a risk factor for their caries development. Other mouth cleaning aids (4%) like fingers, water only, cloth and water, and co on were also being used (especially for the infants) which suggests certain level of awareness among the parents and caregivers. 34 Exclusive breas eeding is advised un l six months of age. However, frequent and long-term breas eeding and bo lefeeding (par cularly night-me) beyond a child's first year of 35 age cause higher early childhood caries. This study showed children being breas ed even for four or more years of age (5.3%) and bo le-feeding con nued beyond two years of age (24.1%). Use of sweetened milk (67.5%) and bed me bo le feeding (49.4%) were also observed. Majority of the parents and guardians reported their child took a sugary diet (83.3%) with 58.9% taking between meals with four or more sugar exposures in a day (12.6%). Also, 32% of the parents and caregivers reported their children taking medicated syrups frequently. An increased caries risk is observed in children having increased frequency of refined sugar exposures, including medicated syrups, between-meal and [36][37][38] at bed me snacks. The American Heart Associa on also recommends that sugar in foods and drinks should be 39 avoided in children under two years of age. The findings of this study indicate the presence of high number of feeding and dietary risk factors that are responsible for developing caries in children. In this study, there was a lack of awareness on the age of child's first dental visit among the parents and caregivers, where the majority reported the age of first dental visit to be only when the problem arose (91%). Almost a quarter (29.5%) of the par cipants were aware that their children had an oral health problem; 39.5% reported decay in their own teeth and their child's sibling's teeth (34%). Surprisingly, the majority of the children (82%) had never had a dental visit, which was greater than prior studies conducted in 40 23 Nepal by Giri M et al , Bastola B et al , and lower than Prasai 24 et al . Among the 18% children who had made dental visits previously, more than half (67.6%) of the children had their last visit more than six months back. The major reasons for their previous dental visits were dental pain (32.4%), loose teeth (22.5%), decayed teeth (31%), and other reasons (swellings and esthe cs) (14.1%). Despite being aware of the presence of oral health issues in the family, the usage of dental services was insufficient, as was the prac ce of regular three-to-six-monthly dental check-ups. They visited the den st only when there was a clear problem. This gap in oral health care among children's parents and caregivers may be due to their lack of awareness of the importance of children's oral health and perceived needs apart from dental fear and anxiety, inaccessibility to dental care and cost of 2 dental treatments. According to studies, even parents and caregivers with good oral health knowledge and a tudes 6 are unable to use it in everyday prac ce. An integrated approach involving primary healthcare prac oners (pediatricians, gynecologists, pediatric den sts, nurses), staff and teachers in child care facili es and schools, and health policy personnel is required to improve child's oral health. All expectant moms should receive oral hygiene counseling and engage in a dental home program, according to the guidelines, so that their infants' oral health can be examined before their first birthday. Furthermore, primary health care providers can provide modest dental treatments (such as fluoride varnish applica on) for those who require it, and government authori es should con nue to promote ini a ves that improve children's oral 3 health. Although this hospital-based study does not reflect a representa ve popula on sample, it can be used as a pilot study. More large-scale (community-based) research are needed to assess parental and caregiver awareness of children's oral health, as well as to iden fy and eliminate barriers to their dental appointments.

CONCLUSION
A substan al number of par cipants reported factors affec ng child oral health, yet there was a lack of awareness about child oral health among parents and caregivers, as well as insufficient use of dental services.

LIMITATIONS OF THE STUDY
Further studies in larger scale (community-based) should be conducted to assess parental and caregivers' awareness on child oral health and barriers for their dental visits to be elicited and eliminated.