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Original Article
Factors associated with a late visit to dentists by children:
A cross-sectional community-based study in Saudi Arabia
Marwah Afeef, MSc
a
,
*
, Nooralhuda Felemban, MSc
b
, Noha Alhazmi, MSc
b
and
Zuhair S. Natto, DrPH
c
a
Study & Research Department, King Fahad Hospital, Jeddah, KSA
b
Department of Oral & Preventive Medicine, King Fahad Hospital, Jeddah, KSA
c
Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, KSA
Received 28 November 2020; revised 6 February 2021; accepted 8 February 2021; Available online 11 March 2021
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ﺟﺪﺓ
Abstract
Objectives: This cross-sectional study aims to determine
children’s age at their first visit to dentists and factors
associated with these visits.
Methods: This cross-sectional community survey-based
study was conducted in 2019 during the events of the
10th Gulf Oral Health Week in Jeddah, Saudi Arabia. All
participants including visitors and dentists, with current
or previous experience in caring for children aged six
months to ten years, provided their consents for the
study.
Results: Among the visitors, 348 participated in the sur-
vey. Most children, aged three to ten years, first visited
the dentist with complaints of pain and dental cavities.
The risk of a late visit to the dentist increased (OR: 2.28;
CI 95%: 1.01e5.14) among caregivers who did not help
their children brush their teeth. Using the Internet for
accessing health information negatively impacted the
visits (OR: 27.00; CI 95% 1.26e57.35). While employed
mothers took their children to the dentist at an earlier age
(OR: 2.284; CI 95% 1.08e4.79), early visits were mostly
missed by mothers with smaller families (OR: 0.043; CI
95% 0.48e0.98).
Conclusion: The results of our study show that the
caregiver’s attitude, source of health information,
employment, age, and number of children are risk factors
associated with late visits to dentists.
Keywords: Cross-sectional; Community; First dental visit;
Caregivers; Dependents; KSA
*Corresponding address: King Fahad General Hospital, Jeddah,
KSA.
E-mail: mbinafeef@yahoo.com (M. Afeef)
Peer review under responsibility of Taibah University.
Production and hosting by Elsevier
Taibah University
Journal of Taibah University Medical Sciences
www.sciencedirect.com
1658-3612 Ó2021 The Authors.
Production and hosting by Elsevier Ltd on behalf of Taibah University. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/). https://doi.org/10.1016/j.jtumed.2021.02.005
Journal of Taibah University Medical Sciences (2021) 16(4), 513e520
Ó2021 The Authors.
Production and hosting by Elsevier Ltd on behalf of Taibah
University. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
Introduction
Oral health is generally considered less important than
general health. However, children should first visit their
dentist as early as the eruption of their first tooth and no later
than their first birthday. This is essential for avoiding early
dental caries; facilitating the detection of early caries lesions;
and helping caregivers in accessing the necessary oral health
information to maintain their dependent’s oral health and
wellbeing.
1,2
In KSA, unlike vaccination, no policies and
practices govern children’s first dental visit, leaving
caregivers to decide on their dependents’ first visit. Studies
conducted in multiple cities in KSA have revealed a high
prevalence of early childhood caries (ECC) among children
aged 6 and younger.
3e6
For instance, the prevalence of
ECC has been documented at 92% and 70e76% among
children in Tabuk and Jeddah, respectively, with similar
results produced in Al Karj and Riyadh.
(4)
Caregivers in
KSA tend to assume that age 3e6 is the optimal time for a
child’s first dental visit, or when they complain of pain.
2,7
Early dental caries are a proven risk factor for caries in
permanent dentition.
8
Thus, to prevent dental caries, the
importance of children first visiting the dentist at an age of
below one year cannot be over-emphasized.
Few studies conducted in KSA investigated the age at
which Saudi Arabian children first visited the dentist and the
factors associated with these visits.
2,7,9,10
For example,
parents attending a dental clinic at King Saud University
in Riyadh city reported a lack of knowledge about the
optimal time to arrange their child’s first dental visit; 62%
of the parents were male.
10
Moreover, Most children first
visited the dentist at the age of 3e5 years.
9
In Abha,
located in the mountainous southern region of KSA, a
convenient sample of caregivers attending dental clinics for
the first time was included in the study. More than 60% of
the children were aged 3e9 years when they first visited the
dentist.
7
These examples indicate a widespread lack of
knowledge about the best age for children to visit the
dentist for the first time. However, it is essential to
recognize the factors contributing to this lack of
knowledge, as opinions and attitudes are not formed in
isolation.
Promoting the utilization of dental services for regular
check-ups and preventive dental procedures is crucial for
maintaining oral health.
11
Since 2002, efforts to promote oral
health have failed to show improvements due to insufficient
knowledge about the social factors behind caregivers’
attitude towards early dental visits. In 1980, a new
approach to disease causation, namely the socio-
environmental approach, was introduced. This approach
recognizes the impact on health outcomes of multiple social
factors, which are referred to as the social determinants of
health.
2,3,5,12
In the city of Jeddah, efforts to contain the prevalence of
caries have not been based on evidence for many years. There
have been no previous studies in Jeddah that determine the
age at which children visit the dentist for the first time, and
little is known about caregivers’ attitudes and levels of oral
care knowledge. Equally essential is breaking the cycle by
asserting the factors associated with the first dental visits of
children in Jeddah.
Thus, this study aims to examine caregivers in the com-
munity to determine the social factors associated with their
dependents’ dental visits; predict what factors influence the
children’s first visit to the dentist, to ensure that these factors
are targeted in future oral health promotion programs;
finally, recommend essential steps to decision makers for
promoting early dental visits, attenuating the prevalence of
ECC, and improving the oral health outcomes of children in
KSA.
Materials and Methods
Study population
A cross-sectional community-based study has been con-
ducted. The inclusion criteria were any caregivers residing in
Jeddah who have currently or had previously cared for
children aged 10 years and younger (6 monthse10 years),
who were attending the 10th Gulf Oral Health Week events
that took place in community centres within Jeddah city,
including the Jeddah seafront area. Convenience sampling
was applied solely in Jeddah, and only those caregivers who
had provided their consent to participate in the study were
included. Caregivers who did not meet our inclusion criteria
of caring, or who refused to participate, were consequently
excluded from the study.
Data collection
The study was based on data analysis from the survey
titled ‘At what age do children of KSA first visit the dentist?’
This survey was conducted during the 10th Gulf Oral Health
Week in Jeddah, KSA, in 2019. Visitors who provided their
consent to participate in the survey were requested to fill out
the questionnaire in Arabic.
The questionnaire was adapted from previous studies
assessing caregivers’ oral healthcare activities and practices
13
and was translated and piloted for content and face validity.
Three experts in paediatric dentistry evaluated each
question’s relevance, clarity, simplicity, and ambiguity.
Face validity was then determined based on the feedback
of ten caregivers whose first language was English, who
were invited to read it, offer their opinions, and state
whether they had found it difficult to understand or answer
any of the questions. A native Arabic speaker translated
the validated English questionnaire into Arabic with the
required modifications. A native English speaker then re-
translated the questionnaire into English, after which the
M. Afeef et al.514
versions in both languages were compared to confirm that
they matched.
The questionnaire consisted of three sections and eighteen
questions. The first section collected data on the caregiver’s
oral health attitude and knowledge; the second on the pre-
vious dental and general health experience; and the third on
the caregiver’s social demographics and characteristics. To
help understand the socioeconomic factors of caregivers, we
used the education level and employment status to avoid
embarrassing caregivers or making them feel uncomfortable
by asking them about their income.
Sample size/power calculations
Sample size was calculated based on the estimated prev-
alence of delayed visit at 30% and 95% confidence interval
using the G*power program (version 3.1.9, Faul F, Erdfelder
E, Lang A-G, & Buchner A, Germany). Therefore, 323
children were needed to achieve the desired estimated pre-
cision of 5%. The final sample size was suggested to be 350 in
case of missing data.
Data analysis
Data were processed using the software Statistical Pack-
age for Social Science (SPSS) version 25 (IBM Corp.,
Armonk, N.Y., USA). Descriptive statistics were used to
describe all independent variables. Association between the
dependent variable of the children’s age at their first visit and
the independent ones (demographics, oral health knowledge,
and attitude) was tested using multinomial regression. P
value of <0.05 was considered statistically significant. Chil-
dren’s age at their first visit was recoded into (early visit age
from 6m to 2y, late visit age from 3y to 10y, and no visits).
Results
Study sample characteristics
A total of 348 questionnaires have been completed and
analysed. Table 1 presents the characteristics of the
participating caregivers, most of whom are female (91.7%)
and the citizens of KSA (76.7%). In terms of age, most of
our participants fall between the age groups of 25e34
(36.8%) and 35e44 (42.2%). Of the participants, (67.5%)
are highly educated, having completed a bachelor’s degree
and above. In addition, only (39.1%) of the participating
caregivers are employed. Most of our participants live in
the northern region of Jeddah (39.2%).
Oral health attitude and knowledge
Caregivers’ oral health attitude and knowledge are illus-
trated in Table 2. More than half of the caregivers (67.8%)
report that they brush their dependents’ teeth, and nearly
half of the caregivers rate their dependents oral health as
fair (52.3%). The two key sources of health information
that most of the caregivers rely on are healthcare providers
(38.8%) and the Internet (30.2%) (Figure 1). Almost all
participants report that their dependents are updated with
their vaccinations (96.3%). Contrarily, only (12.9%) of
them report that their dependents visited the dentist at an
early age (6m to 2y), while (23.6%) report that they never
visited the dentist. More than half of the caregivers
(62.2%) rate their dependents’ behaviour at first visit as
positive. When asked about the reason for their
dependents’ first visit, (37.1%) report cavities to be the
reason.
Factors associated with first visit
Some factors associated with the caregivers’ attitudes
towards their dependents’ first visit to the dentist are outlined
in Table 3. For those caregivers who state that they do not
brush their dependents’ teeth compared with those who
state that they do, the probability of visiting the dentist at
a late age compared with an early age is expected to
increase by (OR: 2.28; CI 95%: 1.01e5.14), given the other
variables in the model are held constant. For those
caregivers who state that they do not brush their
dependents’ teeth compared with those who state that they
do, the probability of never visiting the dentist compared
with visiting at an early age is expected to increase by (OR:
2.81; CI 95%: 1.16e6.81) given the other variables in the
model are held constant. Thus, the act of brushing the
Table 1: The characteristics of the participating caregivers.
Caregiver’s Characteristics n %
Gender
Female 319 91.7
Male 29 8.3
Citizenship
Citizen 267 76.7
Resident 81 23.3
Age group
24 & under 24 6.9
25e34 128 36.8
35e44 147 42.2
45e54 39 11.2
55 & older 10 2.9
Relation to the child
Parent 314 90.2
Sibling 14 4.0
Grandparents 20 5.7
Level of education
Bachelor & above 235 67.5
High school 81 23.3
Intermediate 17 4.9
Elementary 11 3.2
Others (illiterate) 4 1.1
Employment
No 212 60.9
Yes 136 39.1
Location
North Jeddah 127 39.2
South Jeddah 44 13.6
East Jeddah 20 6.2
Middle Jeddah 73 22.5
Out of Jeddah 60 17.2
Late visit to dentists by children 515
dependents’ teeth positively impacts the caregiver’s attitude
about their dependents’ first visit to the dentist.
The model of predicting an early visit to the dentist based
on the caregiver’s opinion about their dependents’ oral
health status is significant with a Pvalue of <0.05. However,
individually, none of the predictors are significant. For those
caregivers who state that they rely more heavily on the
Internet for oral health information compared with those
who state that they rely on posters, the probability of never
visiting the dentist compared with a visit at an early age is
expected to increase by (OR: 13.33; CI 95% 1.99e89.31),
given the other variables in the model are held constant.
Internet utilization for health information therefore con-
tributes negatively to the caregiver’s attitude toward early
dental visits.
For those caregivers who state that they visit the dentist
for preventive measures, such as fluoride, compared with
those who report that they visit the dentist to extract baby
teeth, the probability of visiting the dentist at a late age
compared with a visit at an early age is expected to decrease
by (OR: 0.164; CI 95% 0.02e0.94), given the other variables
in the model are held constant. Thus, regular visits to the
dentist for receiving fluoride promote early visits, thereby
preventing extraction visits for those children.
For those caregivers who are young (24 years and under)
compared with those who are 55 years and older, the prob-
ability of never visiting the dentist compared with a visit at an
early age is expected to increase by (OR: 27.00; CI 95%
1.26e57.35), given the other variables in the model are held
constant. Being a young mother could negatively impact the
child’s first visit to the dentist. For those caregivers who are
not employed compared with those who are, the probability
of never visiting the dentist compared with a visit at an early
age is expected to increase by (OR: 2.284; CI 95% 1.08e
4.79), given the other variables in the model are held con-
stant. Employed mothers confirm that they take their chil-
dren to the dentist at an early age. Surprisingly, if the number
of children were to increase by one, the probability of never
visiting the dentist to an early visit is expected to decrease by
a factor of (OR: 0.68; CI 95% 0.48e0.98), given the other
variables in the model are held constant. Thus, those who
have a smaller number of children are more likely to never
visit the dentist.
Discussion
A dental visit in children’s early years is crucial for them
for ensuring that they are exposed to professional and pre-
ventive dental services as early as possible.
11
This study shows
that most of the children had visited the dentist for the first
0
20
40
60
80
100
Healthcare
providers
Internet Social media campgain Posters
se
s
n
o
pserfo
ega
t
ne
c
reP
Figure 1: Caregivers’ source of oral health information.
Table 2: Caregivers oral health attitude and knowledge.
Items n %
Brushing your dependent’s teeth?
Yes 236 67.8
No 112 32.2
Describing dependent’s OH
Excellent 136 39.1
Fair 182 52.3
Poor 30 8.6
Your source of oral health information?
Social media 54 15.5
Healthcare provider 135 38.8
Campaign 36 10.3
Internet 105 30.2
Posters 18 5.2
First visit to the dentists?
At early age 6m-2y 45 12.9
At late age 3y-10y 221 63.5
Never 82 23.6
Updated with vaccine
Yes 335 96.3
No 13 3.7
Reason for first visit?
Pain 64 24.2
Check up 70 26.5
Cavities 98 37.1
Referrals 2 0.8
Fluoride 19 7.2
Others (extractions of baby teeth) 11 4.2
Dependent’s behaviour?
Negative 99 37.8
Positive 163 62.2
M. Afeef et al.516
time when they were between the ages of 3 and 10 years, and a
small number of children had visited when they were 2 years
old. In addition, the most common reason given for their first
visit is reported to be pain and cavities. Our results agree with
multiple national and international studies investigating the
age of children at their first dental visit. In Riyadh, the
capital of KSA, 3e5 years is revealed as the age at which
most children have their first dental visit.
9
Similar studies in
Bulgaria and India have shown that a greater number of
children visit the dentist for the first time at the age of 3e
10.
14,15
Furthermore, in the United States, multiple studies
have agreed and confirmed that a small percentage of
caregivers had taken their children to their first dental visit
by the age of 2.
2,16
Oral care should begin as early as the eruption of a child’s
first tooth. Multiple factors have been found to be significant
Table 3: Factors associated with first visit to the dentist.
Independent variables Late visit*Never visited*
OR [95% CI] OR [95% CI]
Gender
Female 1.00 [Reference] 1.00 [Reference]
Male 0.57 [0.21e1.54] 0.42 [0.12e1.47]
Citizenship
Citizen 1.00 [Reference] 1.00 [Reference]
Resident 1.11 [0.50e2.46] 1.65 [0.69e3.95]
Age group
24 & under 7.00 [0.60e81.68] 27.00 [1.26e57.35]
25e34 2.05 [0.46e9.01] 6.00 [0.58e61.84]
35e44 3.15 [0.71e13.90] 5.62 [0.54e58.57]
45e54 1.85 [0.36e9.36] 2.57 [0.20e31.71]
55 & older 1.00 [Reference] 1.00 [Reference]
Level of education
Bachelor & above 0.87 [0.44e1.75] 1.09 [0.49e2.40]
High school & under 1.00 [Reference] 1.00 [Reference]
Employment
No 2.11 [1.10e4.05] 2.28 [1.08e4.79]
Yes 1.00 [Reference] 1.00 [Reference]
Location
North 0.69 [0.27e1.76] 0.59 [0.20e1.74]
South 0.56 [0.16e1.92] 1.58 [0.43e5.75]
East 1.07 [0.19e5.89] 1.50 [0.23e9.44]
Middle 1.61 [0.50e5.18] 1.08 [0.28e4.08]
Out of Jeddah 1.00 [Reference] 1.00 [Reference]
Brush dependent teeth
Yes 1.00 [Reference] 1.00 [Reference]
No 2.28 [1.01e5.14] 2.81 [1.16e6.81]
Dependent OH
Excellent 0.60 [0.20e1.78] 2.93 [0.64e13.32]
Fair 2.00 [0.66e6.05] 3.88 [0.82e18.39]
Poor 1.00 [Reference] 1.00 [Reference]
Source of OH info
Social media 1.03 [0.27e3.85] 1.63 [0.24e11.07]
Healthcare providers 1.66 [0.48e5.72] 2.21 [0.36e13.47]
Campaign 1.40 [0.31e6.23] 4.00 [0.53e29.80]
Internet 3.27 [0.80e13.41] 13.33 [1.99e89.31]
Posters 1.00 [Reference] 1.00 [Reference]
Reason for 1st visit
Pain 1.75 [0.31e9.86]
Check up 0.56 [0.11e2.81]
Cavities 1.79 [0.34e9.41]
Fluoride 0.16 [0.02e0.94]
Extraction of baby teeth 1.00 [Reference]
Number of dependents 1.26 [0.95e1.67] 0.68 [0.48e0.98]
Relation to the dependent
Parents 1.52 [0.47e4.91] 2.53 [0.54e11.87]
Sibling 3.07 [0.29e31.98] 4.00 [0.26e60.32]
Grandparents 1.00 [Reference] 1.00 [Reference]
Dependent behaviour
Positive 1.00 [Reference] 1.00 [Reference]
Negative 1.07 [0.54e2.10]
*
Compared with early visit.
Late visit to dentists by children 517
in predicting their first visit to the dentist. For instance,
caregivers’ oral care attitude and knowledge were associated
with their dependents’ first visit to the dentist. Our results
agree with a study confirming that caregivers’ oral health
knowledge and attitude significantly influence the oral health
of their dependents.
16
One of this study’s objectives is to
determine caregivers’ oral health care attitude and
knowledge to identify and amend any gaps, thereby
helping to improve their dependents’ oral health. This
study shows that most of the participating caregivers are
the mothers of the children in their care and are of
childbearing age. Unsurprisingly, our findings agree with a
considerable number of other studies that see mothers as
the primary caregivers of their children, actively involved
in the everyday tasks of caregiving.
17,18
In addition, more
than half of our participating caregivers are highly
educated, with a bachelor’s degree and above. However,
more than half are housewives.
Almost all participants in the study report their de-
pendents to be updated with their vaccinations, indicating
that they view preventive general health measures as impor-
tant and beneficial. In addition, most of the caregivers have
satisfactory oral health knowledge and attitude. An adequate
number of caregivers demonstrate a positive attitude toward
oral care, valuing the act of helping their dependents brush
their teeth. The act of brushing the dependents’ teeth has been
found to positively impact the caregiver’s attitude toward
their dependents’ first visit to the dentist. Moreover, helping
the child to brush their teeth exposes the caregivers to any
changes in their oral health, leading them to take immediate
action if necessary. When caregivers are asked to describe the
health of their dependents’ teeth, nearly half of them rate it as
fair. The caregivers’ perception of their dependents’ oral
health as good, fair, or poor has been found to have a weak
influence on their attitude toward their dependents’ early
visits. Generally, caregivers do not perceive oral health as a
health threat, which explains their attitude towards early
preventive visits. Moreover, most of the children are appar-
ently cooperative, as their behaviour at first visit is largely
rated as positive.
The present study has found that a considerably low
(38.8%) proportion of caregivers utilize healthcare providers
as their key source of health information, and lower than the
proportion (60% and above) reported in multiple studies
assessing caregivers’ knowledge and main source of oral
health information.
19e21
Visiting healthcare providers for
health information is associated with costs and waiting
time. However, the introduction of alternative health
information channels, such as social media and the Internet,
facilitates caregivers’ access to health information with
minimal cost, time, and travel. The public has become
highly skilled in using computers and the Internet. Another
study confirms that participants who report long travel time
for obtaining health information are more likely to access
other communication channels to gain health information.
22
Moreover, the results of this study confirm that the chil-
dren of young mothers are at risk of never visiting the dentist
compared with those of older mothers or caregivers.
23,24
Additionally, the risk of unemployed caregivers and
mothers never taking their dependents to the dentist
compared with taking them at an early age is expected to
increase. Surprisingly, if the number of children were to
increase by one, the risk of never visiting the dentist is
expected to decrease. Therefore, mothers or caregivers with
a smaller number of children are more likely to never visit
the dentist.
25e31
The present findings have some implications. There is
certainly a delay on the first visit to the dentist. Current
strategies to target early childhood caries must consider the
factors associated with delayed dental visits. Further contact
with policy makers may help to manipulate the factors
associated with this delay and promote early dental visits.
Tailored methods are mandatory for appropriately
educating caregivers in recognizing and acting on changes to
their dependents’ oral health. Our findings may encourage
the development of oral health promotion programs target-
ing new mothers and parents of pre-school children.
This study has some limitations that may impact the re-
sults. First, the data collected are self-reported and may
therefore contain bias, as respondents may have been too
embarrassed to disclose private details. Thus, bias and social
desirability may affect the results. Additionally, oral
screening should have been included, as this would have
provided insight into the dependents’ oral care and health
status.
Conclusion
This is the first community study in Jeddah city deter-
mining the age and factors associated with children’s first
visit to the dentist. Caregivers’ attitude, source of health in-
formation, employment status, age, and the number of
children that they care for are found to be major risk factors
for dental visits. Establishing practices to promote early
dental visits not later than the age of 1 is crucial. Finally,
raising caregivers’ awareness about the age at which their
children must first visit the dentist, and about these visits’
significance, may be the first step in promoting the preven-
tion of early childhood caries.
Recommendations
Oral health initiatives targeting new caregivers will help
promote their dependents’ oral health; the provision of oral
prophylaxis and workshops on appropriate oral care would
empower caregivers to support and improve their children’s
oral health. Moreover, healthcare providers must deliver
concise and clear professional oral health messages advising
caregivers to take their dependents for a visit to the dentist no
later than the age of 1. Additionally, the caregivers of
preschool-age children must receive sufficient attention, with
preventive oral health initiatives dsuch as fluoride varnish
campaigns dtargeting this age group.
Source of funding
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
Conflict of interest
The authors have no conflicts of interest to declare.
M. Afeef et al.518
Ethical approval
The study protocol was registered with the Research and
Studies Department- Jeddah Health Affairs. The IRB
registration number with KACST, KSA: H-02-J-002/;
Research number: 01038. All participants gave written
informed consent before participating in this study. Ethical
Approval was done by ethical committee of Jinnah Post
Graduate Medical Centre (No. F 5-89/2015/GENL/599/
JPMC dated 1st February 2015).
Authors contributions
MA, the first author, contributed to this study by help-
ing in the conception, design, defining intellectual content,
literature search, data analysis, manuscript preparation,
editing, and review, and will be the manuscript guarantor.
The second author, NF, contributed to this study by help-
ing in the conception, design, defining intellectual content,
literature search, and manuscript preparation, editing, and
review. The third and the fourth author, NA and ZN,
contributed to this study by helping in the conception,
design, defining intellectual content, literature search, and
manuscript preparation, editing, and review. All authors
have critically reviewed and approved the manuscript’s final
draft and are responsible for its content and similarity
index.
Acknowledgement
I wish to express my gratitude to The Department of Oral
Preventive Medicine at Jeddah Dental Administration for
helping us with data collection.
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How to cite this article: Afeef M, Felemban N, Alhazmi
N, Natto ZS. Factors associated with a late visit to den-
tists by children: A cross-sectional community-based
study in Saudi Arabia. J Taibah Univ Med Sc
2021;16(4):513e520.
M. Afeef et al.520
