0021-7557/$ - see front matter © 2013 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.
J Pediatr (Rio J). 2013;89(2):116−123
☆Please, cite this article as: de Castilho ARF, Mialhe FL, Barbosa TS, Puppin-Rontani RM. Influence of family environment on children’s
oral health: A systematic review. J Pediatr (Rio J). 2013;89:xx-xx.
* Corresponding author.
E-mail: email@example.com (A.R.F. de Castilho).
Influence of family environment on children’s oral health:
a systematic review☆
Aline Rogéria Freire de Castilhoa, Fábio Luiz Mialheb, Taís de Souza Barbosac,
Regina Maria Puppin-Rontanid
aPhD in Pediatric Dentistry, Department of Biological Sciences, Bauru Dental School, Universidade de São Paulo (USP),
Bauru, SP, Brazil
bPhD, Associate Professor, Department of Community Dentistry, Piracicaba Dental School, Universidade Estadual de
Campinas (UNICAMP), Piracicaba, SP, Brazil
cPhD in Pediatric Dentistry, Department of Pediatric Dentistry, Piracicaba Dental School, UNICAMP, Piracicaba, SP, Brazil
dPhD, Full Professor, Department of Pediatric Dentistry, Piracicaba Dental School, UNICAMP, Piracicaba, SP, Brazil
Received 8 October 2012; accepted 17 October 2012
Objective: To review current models and scientific evidence on the influence of parents’
oral health behaviors on their children’s dental caries.
Sources: MEDLINE articles published between 1980 and June, 2012. Original research
articles on parents’ oral health behavior were reviewed. A total of 218 citations were
retrieved, and 13 articles were included in the analysis. The studies were eligible for
review if they matched the following inclusion criteria: (1) they evaluated a possible
association between dental caries and parents’ oral-health-related behaviors, and (2)
the study methodology included oral clinical examination. The main search terms were
“oral health”, “parental attitudes”, “parental knowledge”, and “dental caries”.
Summary of the findings: 13 experimental studies contributed data to the synthesis.
Original articles, reviews, and chapters in textbooks were also considered.
Conclusion: Parents’ dental health habits influence their children’s oral health. Oral
health education programs aimed at preventive actions are needed to provide children
not only with adequate oral health, but better quality of life. Special attention should
be given to the entire family, concerning their lifestyle and oral health habits.
© 2013 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda.
All rights reserved.
Parents’ oral-health-related behaviors 117
Atitutes dos pais;
Influência do ambiente familiar sobre a saúde bucal de crianças: uma revisão siste-
Objetivo: Envolver modelos atuais e comprovações científicas sobre a influência dos
comportamentos dos pais relacionados à saúde bucal sobre a situação de cáries dentárias
Fontes: Artigos do MEDLINE publicados entre 1980 e junho de 2012. Foram analisados
artigos de pesquisa originais tratando do comportamento dos pais quanto à saúde
bucal. Um total de 218 citações foi analisado e 13 artigos foram incluídos na análise.
Os estudos foram considerados elegíveis para análise se atendessem aos seguintes
critérios de inclusão: (1) avaliassem uma possível associação entre cáries dentárias e o
comportamento dos pais relacionado à saúde bucal; e (2) se a metodologia do estudo
incluísse exame clínico bucal. Os principais termos de pesquisa foram “saúde bucal”,
“atitudes dos pais”, “conhecimento dos pais” e “cáries dentárias”.
Resumo dos achados: Ao todo, 13 estudos experimentais contribuíram com dados para a
síntese. Também foram considerados trabalhos, revisões e capítulos originais em livros
Conclusão: Os hábitos de saúde dental dos pais influenciam a saúde bucal de seus filhos.
São necessários programas de educação em saúde bucal com ações preventivas para
proporcionar não apenas saúde bucal adequada às crianças, mas também uma melhor
qualidade de vida. Deve ser dada atenção especial a toda a família, com relação a seu
estilo de vida e hábitos relacionados à saúde bucal.
© 2013 Sociedade Brasileira de Pediatria. Publicado por Elsevier Editora Ltda.
Todos os direitos reservados.
Parents’ habits and knowledge about oral health have
been found to influence their children’s oral health
status.1-3 Children with poor oral health habits are
more likely to develop dental caries when compared
with those who have favorable habits.4-6 Moreover, low
socioeconomic status of the family7-9 and parents’ poor
oral health habits1,10 have also been found to contribute
to the development of dental caries. In addition, other
factors such as gender11 and multiple levels of influence,
including time or developmental dimensions,12 have been
Since oral hygiene is essential to oral health, it is wise
to provide the population with adequate guidelines on
children’s oral health behavior and its relationship with
dental caries. It is helpful to address the factors that
influence children’s oral health in order to develop and
implement complementary public health actions focused
on children and parental behaviors, in an endeavor to
provide them with good oral health and better quality
This literature review comprises a number of current
models and scientific evidences regarding the influence of
parents’ oral health behaviors on their children’s dental
Data sources and study selection
The authors searched the MEDLINE database for articles
published from 1980 to the end of June 2012, supplemented
by manual searching of the references from each relevant
The studies were eligible for review if they matched the
following inclusion criteria: (1) they evaluated a possible
association between dental caries and parents’ oral
health related behavior, and (2) the study methodology
included oral clinical examination. Furthermore, original
articles, reviews, and chapters in textbooks were also
Data extraction and synthesis
The main search terms were “oral health”, “parental
attitudes”, “parental knowledge”, and “dental caries”.
A total of 218 records were originally retrieved. Two
reviewers selected and reviewed the articles. First, each
reviewer independently selected the articles based on their
abstracts and checked their contents. Then, they looked
for articles without abstracts. An agreement of 100% was
obtained between the two reviewers.
118 de Castilho AR et al.
A consensus was reached regarding the studies that
fulfilled the inclusion criteria (13 articles), and which were
included in this review.
Of the 13 studies that met eligibility criteria, eight1,2,10,13-17
related caries to parents’ self-care practice, five described
sugar as being responsible for caries,1-3,9,18 two19,20 described
the influence of parents’ socioeconomic status on children’s
oral health; and two3,21 associated the mothers’ age with
caries in their offspring.
A summary of each selected article is presented in Table 1.
Parents harboring cariogenic bacteria
Negligence towards oral hygiene is widely known as
the leading cause of dental caries. The oral cavity of a
newborn is basically free of microbes. Soon after birth,
numerous bacteria, including Streptococcus mutans, start
to develop in their mouth. Since saliva flow is reduced
during sleep, cariogenic bacteria gain prolonged access to
fermentable substances, in a process that leads to dental
The colonization of mutans streptococci in a child’s mouth
is directly related to the risk of caries. It is known that S.
mutans is the most decisive microorganism for the onset of
caries, while S. sobrinus is related to the progression and
development of carious lesions.23 For this reason, children
harboring both S. mutans and S. sobrinus species experience
more caries than those only S. mutans or S. sobrinus.24-26
Maternal habits and behaviors may sometimes stimulate
or increase microbial contamination in the child’s oral
cavity. The frequent contact between mother and child may
cause early contamination and transmission of bacteria.27
Mothers are known to be the first to infect their
children with cariogenic bacteria,28 suggesting that their
DMFS (number of decayed, missing, and filled surfaces
of permanent teeth) might be a good indicator of caries
experience in their children.29,30 High levels of S. mutans
in mothers increase their children’s chance of developing
dental caries by 11 times. A reduction in the number of S.
mutans in the saliva of highly infected mothers is appropriate
in order to avoid colonization by these microorganisms of
their children’s oral cavity. This is an important aspect
that should be assessed, since the earlier the child is
contaminated by cariogenic microorganisms, the higher
the risk of early caries development.27,31 Furthermore, the
parents’ previous caries experience has been found to have
a negative impact on their child’s oral health.1,3
Colonization with mutans streptococci leads to early
caries development, and should be targeted for caries
Table 1 Summary of references appraised.
Reference Source Sample size Age, y Selected findingss
1 Mattila et al. 1,074 7 Caries are related to parents’ health habits,
sugar consumption, and frequency of
Caries are related to parent’s ability to control
children’s toothbrushing and sugar consumption
Caries are related to sugar intake, rural
domicile, and mother’s age
Parents social group and sugar intake influence
Parents’ oral health behavior affected their
children’s oral health behavior
Mother’s oral health knowledge and attitudes
are associated with caries
Mother’s oral self-care is related to their
offspring’s oral health
Caries experience of mother’s and practice
of health knowledge affects their children’s
C aries are related to parents’ self-care oral
Caries are related to parents’ self-care
Consumption of sugar at night increases caries
Occupational status of the parents affects
children’s oral health
Caries are related to mother’s age
2 Adair et al. 2,822 3-4
3 Mattila et al. 828 5
9 Flinck et al. 3,373 12
10 Okada et al. 296 7-12
13 Saied-Moallemi et al. 457 9
14 Saied-Moallemi et al. 459 9
15 Castilho et al. 200 5
16 Poutanen et al. 489 11-12
17 Sundby et al. 794 3-5, 7, 15
18 Paunio et al. 1,582 3
20 Vanobberge et al. 1,500 7
21 Paunio et al. 1,582 3
Parents’ oral-health-related behaviors 119
prevention in clinical practice.32 Although transmissibility
is fundamental for the onset of caries, other factors, such
as quality of oral hygiene, also influence the development
of this disease.33 Therefore, strategies for the prevention of
dental caries should focus on controlling the colonization of
cariogenic bacteria in young children,34 and parents should
be encouraged to have better oral health behaviors on a
Parents’ toothbrushing habits and children’s
The association between parental toothbrushing
and caries in children
Parents’ toothbrushing habits were found to influence
their children’s toothbrushing behaviors. This hypothesis
was confirmed by an international study involving 17
Considering that regular toothbrushing and flossing
eliminate cariogenic bacteria and fermentable substances
from the tooth surfaces, good oral hygiene habits help
prevent some oral pathologies, such as periodontal
diseases and dental caries, which are considered common
public health problems. At different ages in childhood,
toothbrushing habits should be introduced to children
by their parents or care-givers, and practiced on a daily
basis.36 Therefore, an educational approach targeting both
children and their parents would help them to suffer fewer
carious lesions, and to have better oral health and quality
Importance of interventions to improve parental
Parents’ oral health behaviors have a direct influence on
the number of decayed teeth of their children, indicating
that oral health strategies should be focused not only on
children but also on their parents.10 Children of parents who
control their children’s toothbrushing and sugar intake have
favorable oral health habits, demonstrating that parental
attitudes have a positive impact on their children’s oral
In fact, the higher the parents’ education level, the more
favorable the oral self-care of their children. Maternal oral
health habits undoubtedly influence her children’s oral self-
care, emphasizing the mothers’ role in the oral health of
their offspring; therefore, oral health educational programs
focusing on these aspects should be developed.13,14
Although most mothers (71%) are aware of the need
for daily-supervised toothbrushing, only approximately
40% do so. Moreover, only 40% of the children were found
to carry out their own oral hygiene.38 While oral hygiene
habits, frequency of dental visits, and consumption of
healthy foods tend to be over-reported, the consumption
of sugar-containing products is likely to be under-reported,
since respondents often give socially expected answers.39
When interviewed, most mothers appear to recognize
the importance of oral hygiene and demonstrate some
knowledge of oral health, as they provide satisfactory
responses. However, the caries index observed for children
and the oral health status of their mothers imply that this
epidemiological approach has failed to assess the oral
health of those attending the educational programs aimed
to prevent oral diseases.39
Castilho et al. found that 47% of the mothers reported
that their children brushed their teeth three times a
day; only 32% of these mothers were found to brush the
teeth of their children, while most (68%) only supervised
the toothbrushing. However, a caries index (mean DMFT:
5.8) analysis revealed an incompatibility between the
toothbrushing frequency performed by the children and
that reported by their mothers.15
According to Finlayson et al., during the process of
learning to brush, children only play with the toothbrush
in their mouths, and do not actually clean their teeth.40
Therefore, mothers play a key role in helping their children
by teaching them favorable oral health habits.40 Children
born to mothers who are aware of the importance of oral
hygiene are found to brush their teeth more frequently,
because they develop better brushing habits.40
Interestingly, parental self-efficacy is associated with
insecurity about correct toothbrushing techniques, but
mostly, to a self-reported oversensitivity to the child’s
desires for some particular foods or not liking to brush.41
Although parents try their best to adopt a healthy lifestyle,
some similarities and differences towards oral health are
found between genders. Favorable oral habits are more
often reported by girls.16 According to their self-reported
behaviors, girls’ parents belong to a more satisfactory
lifestyle group when compared with boys’ parents.16
Furthermore, girls brush their teeth more regularly than
boys,11 probably due to the fact that they are more likely
to follow the footsteps of their mothers, while boys tend
to emulate their fathers. Therefore, more attention should
be given to parents, since they influence their children’s
behaviors in a general way.19
Parental knowledge, attitudes, and socioeconomic
Widely investigated parental characteristics such as
knowledge, attitudes, and socioeconomic status influence
children’s oral health behaviors.
Cultural norms and practices influence a large variety
of social factors, such as values, beliefs, and customs,
affecting children’s oral health. Culture comprises religion,
health beliefs, language, diet, family structure, and medical
and dental preventive approaches.2,42
The association between children’s poor oral health
and low socio-economic status of the family is clear.7-9
According to Mattila et al., the mainly factors correlated
with children’s caries index (DMFT) at the age of 5 years
are: mother’s young age, parents’ cohabitation, rural
dwelling, parents’ poor caries history, mother’s poor dental
hygiene habits, child’s sugar consumption before the age of
18 months, and child’s headache at the age of 5 years.3
The fact that mothers of children in ethnic minority
groups often receive only a few years of education results
in poor communication skills, and consequently poor dental
health.17 Likewise, woeful living conditions and irregular
oral health practices also contribute to the differences in
dental caries prevalence.17 In addition, sociodemographic
characteristics affect oral health knowledge and attitudes
120 de Castilho AR et al.
of parents with a lower level of education, and negatively
affect their oral health practices.43 A higher prevalence of
dental caries and lower toothbrushing frequency was found
in 3-year-old children living in rural areas, when compared
with those from urban settings.18,21
When considering socioeconomic status, children who have
fathers with a high occupational status and stay-at-home
mothers presented the lowest caries index values (DMFT =
1.3; DMFS = 2.5),20 While children from higher social classes
were shown to experience fewer caries,44 children from
lower classes have the poorest dental health.45 In summary,
parents’ age and educational levels are important social
background factors that directly influence their children’s
Based on several studies, the key elements that showed
particular impact on children’s oral health behavior and oral
health status were: parents’ oral health-related attitudes,
general knowledge, and health status.1-3 When all these key
elements were compared, parents’ behaviors appeared to
be more strongly related to children’s behavior than are
parents’ knowledge and attitudes, supporting the findings
that children learn behaviors from their parents.47 Mothers’
oral health-related knowledge has been associated with
dental caries in 3-year-old children.48
Although parental factors are known to influence
children’s dental health, there are differences between
study models for boys and girls. Boys were influenced
by their father’s occupational level, while girls were
influenced by their father’s knowledge and behavior. Taking
these findings into consideration, school health educational
interventions involving the entire family are needed to
provide children with more adequate preventive guidelines
in order to ensure the success of their oral health.16
It is remarkable that the day-to-day life of families is
largely influenced by social, cultural, environmental,
and economic conditions. These social aspects play key
roles in oral health, with positive or negative influence
on the adoption of particular oral health attitudes and
Early education and implementation of preventive
measures at home
Clearly, family environments encourage healthy choices
and lifestyles.49 Ideally, dental professionals should inform
parents of the influence that their dental health behaviors
and attitudes might have on their children’s oral health,
including the benefits of pediatric oral care, oral health
educational programs, and other dental-health-related
Although parents play the most important role in the
oral health of their children, schoolteachers are also
important and should be involved in children’s oral health
education.50,51 Children spend a considerable amount of
time at school, where they can be taught good health
habits.50 Teachers could emphasize the importance of
consuming fewer sugary foods and drinks, especially during
school time, and oral health education activities should be
included in the general curriculum.51
Early oral health education and preventive measures help
reduce the need for future surgical interventions. However,
the parents must be able to assimilate the information,
understand the instructions provided, and implement
them as part of the child’s preventive oral health routine.
Unfortunately, many adults are only partially literate, and
consequently, have more difficulty in understanding the
instructions on dental caries prevention.52
In summary, parents’ dental hygiene habits, educational
backgrounds, and child-rearing abilities have a favorable
effect on their children’s dental health status. Contextual
aspects related to a family’s capacity to develop and
maintain good dental health behaviors are relevant in
pediatric dentistry, since parents with poor dental health
behaviors indicate caries risk in their children.3
Recommendations on children’s oral health care
A better understanding of social, economic, belief,
behavioral, and attitudinal factors is crucial in studies with
the goal of oral health promotion.
A central model based on oral health promotion efforts
(1970s–1980s) was developed to provide the population with
substantial knowledge and guidelines on oral health-related
behaviors. A wider outlook involving multiple determinants
of oral health53 is needed to encourage individuals from
different backgrounds to adopt a healthy lifestyle.54
Socioeconomic disparities account for part of the oral
health behaviors involving the whole family. Oral health
policies designed to change behaviors are unlikely to
completely eliminate disparities in oral health.55-57
According to Kay & Locker, health education is helpful
in raising the level of knowledge, and in changing both
attitudes and beliefs.58 Health promotion programs
provide not only schoolchildren, but also their parents,
with adequate information on dental care involving oral
health habits and attitudes. The entire family should take
responsibility for their dental hygiene.4
Health-influencing factors are addressed at individual,
family, and community levels.59-61 In fact, simple
models based on each individual are limited and no
longer acceptable. Children live in families; families
are included in communities. Therefore, effective
community initiatives, such as oral health promotion and
public approaches are related to children’s oral health.
Communities that value oral health lead to children with
better oral health.62
Oral health is correlated with general health.63 the
mouth is part of the body and A child’s risk of developing
oral diseases is as high as his/her risk of developing overall
illnesses.64,65 Similarly, it is impossible to separate the
family’s and society’s risks for disease from the child’s risk
for the development of both general and oral pathologies.
Consequently, any approach to children’s oral health must
be based on a multilevel outlook as a means to achieve
The idea behind motivating both the individual and
community must be understood. Individuals at the highest
risk of caries with the lowest motivation are the most
difficult patients to work with during the practice of oral
The key concept of the health promotion approach is
the empowerment of individuals. This strategy should be
Parents’ oral-health-related behaviors 121
implemented in order to improve the individual’s control of
his/her life.68 Nevertheless, changing people’s behavior and
getting them to maintain it is a great challenge to health
professionals. Poor parental oral health behaviors are likely
to be caries predictors for their children.35 Therefore, all
aspects associated with the family’s process of acquiring
and maintaining good oral health behaviors are aspects
with an impact on pediatric dental health care.3,69
Shared decision-making functions as a favorable
communication tool between professionals and patients
in health care.70,71 Efforts to listen,72 family dialogue, and
evaluation of family resources are important factors, and
contribute enormously to this interaction.73 Furthermore,
the dental staff should listen carefully to family members
in order to provide them with adequate guidelines on dental
care and oral health-related habits.
Caries, the most frequent oral disease, are preventable
with the adoption of effective interventions in the
individual’s lifestyle and habits, including oral hygiene.
However, the population’s cooperation is a dominant factor
in every preventive approach, because knowledge and
information are not enough to promote oral health. In fact,
oral health promotion is highly dependent on good health
behaviors.67 Unfortunately, the power of traditional health
education is limited regarding pediatric oral care, and has
sometimes failed to change health behavior.58,74
Successful preventive actions against oral diseases
involve environmental modifications and development
of strategies that enable people to choose a healthier
lifestyle75 by creating resources that guide them to a more
active and productive life, resulting in good health status,
and consequently, a satisfactory quality of life.68
Reducing inequalities in oral health continues to be the
greatest dental public health challenge.56 Individuals at
the top of the social hierarchy experience better health
conditions than those in the lower social hierarchy. This
social gradient is constantly associated with minor illnesses
and causes of death, affecting all age groups, genders,
races, and countries.76-79 When considering these oral
health inequalities, an effective approach is necessary in
order to identify and understand the fundamental causes of
dental caries. According to public health studies, biological,
psychosocial, behavioral, environmental, and political
factors are observed to be the cause of dental diseases.
Social determinants of oral health inequalities undoubtedly
have some influence on oral health; however, the broader
background that determines patterns of behavior must be
deeply analyzed in order to create a social environment
that supports good oral health habits.56
The development and implementation of satisfactory
public health actions at different levels (local, national,
and international) are essential for health promotion.68
A longitudinal component is needed to measure the
influence of time and the elements related to oral health
at a variety of levels — individual, family, and community.12
Complementary public health approaches, such as strategy
development, organizational change, community action,
and legislation,62,74 focusing on both individuals and
communities, not only on high risk individuals, would
help to prevent carious diseases and to promote good oral
The adoption of consistent behavioral habits in childhood
begins at home, with the parents, especially the mother,
playing an important role in the child’s oral health-behaviors.
Parents should be informed that their dental health habits
influence their children’s oral health, and consequently,
their quality of life. Therefore, a more soundly based
health educational program involving all family members is
needed to provide parents with adequate guidance on how
to maintain the oral health of their children.
Conflicts of interest
The authors have no conflicts of interest to declare.
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