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Oral health has been described as an important
feature of well-being. Therefore, abnormalities in
dental conditions play an important role in the way
people perceive their own oral health (1, 2). Over
the last 30 years, the use of sociodental indicators
to measure self-perceived oral health has been
widely advocated (3–6), because when normative
indicators of oral disease are used alone, they
do not document the full impact of oral disorders
(7–9).
Evidence suggests that self-rated oral health was
associated with clinical and background conditions
in adults and the elderly (10–12). This relationship
has not been well established in preschool children,
probably because these children are unable to
complete the questionnaire and provide complete
information. Therefore, the parents are included as
proxies (13).
Parents’ perceptions of their child’s oral health
could influence the oral health decisions and
patterns of health care (14). It has been suggested
that these perceptions could be associated with
clinical and socioeconomic conditions (15–17). An
American population-based study found that car-
ies, the perceived need for dental cleaning and
treatment, lower income, and poorer general health
perceptions were associated with poorer parents’
perception of their children’s oral health (16).
Community Dent Oral Epidemiol 2011; 39: 260–267All rights reserved
� 2010 John Wiley & Sons A/S
Socioeconomic and clinicalfactors associated withcaregivers’ perceptions ofchildren’s oral health in BrazilPiovesan C, Marquezan M, Kramer PF, Bonecker M, Ardenghi TM. Socioeco-nomic and clinical factors associated with caregivers’ perceptions of children’soral health in Brazil. Community Dent Oral Epidemiol 2011; 39: 260–267.� 2010 John Wiley & Sons A ⁄ S
Abstract – Objectives: We assessed how socioeconomic and clinical conditionscould affect parents’ perceptions of their child’s oral health. Methods: A cross-sectional study was conducted in a sample of 455 children, aged 1–5 years,representative of Santa Maria, a southern city in Brazil. Participants wererandomly selected among children attending a National Day of Children’sVaccination. Clinical examinations provided information on the prevalence ofcaries, dental trauma, and occlusion. The caregivers’ perception of children’soral health and socioeconomic status were assessed by means of aquestionnaire. A Poisson regression model using robust variance (Prevalenceratio: PR; 95% CI, P £ 0.05) was performed to assess the association between thepredictor variables and outcomes. Results: Parents were more likely to ratetheir child’s oral health as ‘poor’ if the former earned a lower income and thelatter had anterior open bite and dental caries. Parents of black children withanterior open bite and dental caries were more likely to rate their child’s oralhealth as ‘worse than that of other children’. Conclusions: Clinical andsocioeconomic characteristics are significantly associated with parents’perceptions of their child’s oral health. Understanding the caregivers’perceptions of children’s oral health and the factors affecting this could beuseful in the planning of public health polices, in view of the inequity in the oralhealth pattern.
Chaiana Piovesan1, Macela Marquezan2,
Paulo F. Kramer3, Marcelo Bonecker4 and
Thiago M. Ardenghi5
1Department of Stomatology, Universidade
Federal de Santa Maria (UFSM), Santa Maria,
RS, Brazil, 2Department of Restorative
Destistry, Universidade Federal de Santa
Maria (UFSM), Santa Maria, RS, Brazil,3Department of Paediatric Dentistry,
Universidade Luterana do Brasil, Canoas,
RS, Brazil, 4Departament of Paediatric
Dentistry, Universidade de Sao Paulo, Sao
Paulo, SP, Brazil, 5Department of
Stomatology, Universidade Federal de Santa
Maria (UFSM), Santa Maria, RS, Brazil
Key words: dental services research;epidemiology; health perceptions
Thiago Machado Ardenghi, RuaCel.Niederauer 917 ⁄ 208, Santa Maria, RS97.015-121, BrazilTel.: +55 55 9998 9694e-mail: [email protected]
Submitted 9 June 2010;accepted 19 November 2010
260 doi: 10.1111/j.1600-0528.2010.00598.x
A theoretical explanation of the link between
socioeconomic status and oral health focuses on the
effect of psychosocial variables on individual life-
style decisions. This perspective argues that health
inequalities result from differences in the experi-
ence of psychological stress between socioeconomic
groups (18), with individuals from lower socioeco-
nomic backgrounds experiencing a higher number
of negative life effects (19), lower levels of social
support (20), and living in communities with higher
levels of antisocial behavior (21). This evidence
supports the indirect model, which proposes that
people experiencing higher levels of psychosocial
stress are more likely to make behavioral or lifestyle
choices that are damaging to health (20). However,
in most developing countries, data on caregivers’
perceptions of oral health are scarce. In Brazil,
although previous studies have assessed predictors
for self-rated oral health in adolescents and the
elderly (22–24), no study has previously addressed
the caregivers’ perceptions of children’s oral health.
An understanding of the socioeconomic and
clinical factors associated with caregivers’ percep-
tions of children’s oral health could be important
information when planning public health policies,
in view of the inequity in the oral health pattern of
the target population. Therefore, a cross-sectional
study was performed in a representative sample of
1- to 5-year-old Brazilian children, to assess the
influence of socioeconomic and clinical conditions
on caregivers’ perceptions of children’s oral health.
Methods
SampleA cross-sectional study was conducted in a repre-
sentative sample of 1- to 5-year-old children living
in the city of Santa Maria, RS, located in the south of
Brazil. The city has an estimated population of
263 403, including 27 520 children under the age of
6 years. It was estimated that a minimum sample
size of 435 children was required to achieve a level
of precision with a standard error of 5% or less. The
95% confidence interval level and an estimated
prevalence of 50% of the outcome (caregivers’ ‘poor’
perception of children’s oral health) were used to
calculate the sample size. The decision to use a
prevalence of 50% was owing to a lack of informa-
tion on the actual prevalence of the outcome.
Participants were randomly selected among
the children attending a National Day of Chil-
dren’s Vaccination. The vaccination program had
consistent uptake rates of over 97% for all the 5- to
59-month-old children living in the city. The age of
the children who participate in the National Day of
Children’s Vaccination ranges from 0 to 59 months.
A sampling quota was selected from all the
children who attended health centers in the city
of Santa Maria. Health centers were used as
sampling points because the city was administra-
tively divided into five regions, and each had
public health centers that were responsible for the
vaccination of the residents in that area. For this
study, eight health centers were cluster selected
from a total of twenty in the city.
Data collectionData were collected by means of clinical oral exam-
inations and structured interviews. In all, 8 examin-
ers and 24 support team members participated in the
study. They were previously trained and calibrated
for data collection before the survey. During the
survey, every fifth child in the vaccination queue
was invited to participate. If the parents did not wish
to participate, the next parent in the queue was
selected. To avoid a selection bias, siblings were
excluded. This random process was the same at all
the eight health centers. Children were examined in
a dental chair. Their teeth were dried and examined
under standard illumination provided by a conven-
tional operating light. Clinical examinations to
record dental caries, that is, dmft (25); dental trauma
(26); and occlusal patterns were performed.
Data on the socioeconomic status of the target
population were collected by means of a structured
questionnaire. The questionnaire presented a series
of questions regarding socioeconomic and demo-
graphic characteristics such as age, sex, mother and
father’s educational levels, race, family income, and
mother’s occupation. The educational level com-
pared those fathers and mothers who completed
8 years of formal instruction, which in Brazil corre-
sponds to primary school, with those who only
completed a lower education (<8 years of formal
education). Household income was measured in
terms of the Brazilian minimum wage, a standard
for this type of assessment, which corresponded to
approximately 280 US dollars during the period of
data gathering. Occupational status discriminated
the employed and unemployed parents. The ethnic
groups of the children were assessed according to
their mother’s self-report. The survey adopted a
classification of the ethnic groups according to the
criteria established by the agency for demographic
analysis – the Brazilian Institute of Geography and
261
Caregiver’s perception of child’s oral health
Statistics (27). According to these criteria, children
were classified as ‘black’ (black children of African
and mixed descent) and ‘white’ (children of Euro-
pean descent).
Data about the parents’ perceptions of their
child’s oral health were measured by the following
questions: (1) ‘Would you say that your child’s oral
health is 1 – excellent, 2 – good, 3 – fair, or 4 – poor?’
[This was dichotomized into good (codes 1 and 2)
and poor oral health (codes 3 and 4).] and (2) ‘How
do you describe your child’s oral health? 1 – Worse than
that of other children or 2 – Better than that of other
children’. The feasibility of the questionnaire was
previously assessed in a sample of 20 parents
during the calibration process.
AnalysesData analyses were performed using stata 9.0.
Descriptive and bivariate analyses were conducted
to provide summary statistics and a preliminary
assessment of the association of predictor variables
and outcomes. In the analyses, the following two
outcomes were considered: Prevalence of the par-
ents who rated their child’s oral health as ‘poor’ and
prevalence of the parents who rated their child’s
oral health as ‘worse than that of other children’.
A Poisson regression model using robust vari-
ance (PR; 95% CI, P £ 0.05) was performed to assess
the association between the predictor variables and
outcomes. A backward stepwise procedure was
used to include or exclude explanatory variables in
the fitting of models. Explanatory variables pre-
senting a P value £ 0.20 in the assessment of
correlation with each outcome (bivariate analyses)
were included in the fitting of the model. Explan-
atory variables were selected for the final models
only if they had a P value £ 0.05 after adjustment.
EthicsThis study observed the international statutes and
national legislation on ethics in research involving
human beings. All the children consented to
participate, and their parents (mothers or fathers)
signed a term of consent. The study protocol was
approved by the Committee of Ethics in Research
of the Federal University of Santa Maria.
Results
A total of 455 children, 53.8% boys and 46.2% girls,
were enrolled in the study. The response rate was
98% of all the invited children. Table 1 summarizes
the demographic characteristics of the sample. The
percentage of participating children was similar
across the different age groups. The children were
predominantly white, and their caregivers had a
high level of education. More than half the mothers
were unemployed, with a household income ‡3
Brazilian minimum wage (BMW). The majority of
the children had adequate sealing lip, and only
34% of the sample had anterior open bite. Preva-
lence of dental caries and dental trauma were
23.5% and 31.5%, respectively.
Prevalence of the parents who rated their child’s
oral health as ‘poor’ were associated with age,
household income, mother’s level of education,
Table 1. Sociodemographic and clinical characteristics ofthe sample
Variable n* (%)
Sociodemographic characteristicsChild’s gender 455
Male 245 53.8Female 210 46.2
Child’s age (years) 454£2 215 43.43 120 26.4‡4 119 26.2
Child’s ethnicity 455White 345 75.8Black 110 24.2
Household income 444<3 BMW 203 45.7‡3 BMW 241 54.3
Mother’s schooling 444<8 years 129 29.1‡8 years 315 70.9
Father’s schooling 414<8 years 122 29.5‡8 years 292 70.5
Mother’s occupation 447Unemployed 240 53.7Employed 207 46.3
Father’s occupation 414Unemployed 32 7.7Employed 382 92.2
Clinical StatusSealing Lip 435
Adequate 342 78.6Inadequate 93 21.4
Anterior Open Bite 406No 268 66.0Yes 138 34.0
Dental caries 455dmf = 0 348 76.5dmf > 0 107 23.5
Dental trauma 441Without 302 68.5With 139 31.5
BMW, Brazilian minimum wage.*Values lower than 455 due missing data.
262
Piovesan et al.
presence of anterior open bite, and dental caries
(Table 2). However, in the multiple regression
analyses, only clinical variables and household
income remained associated with the outcome.
Parents were more likely to report their child’s oral
health as ‘poor’ when the former had a low
household income and the latter had anterior open
bite and dental caries.
Table 3 expresses the prevalence of the parents
who rated their child’s oral health as ‘worse than
that of other children’ and the associated factors. In
the final model of the multiple regression analyses,
the parents of black children with anterior open
bite and dental caries were more likely to rate their
child’s oral health as ‘worse than that of other
children’.
Discussion
The primary purpose of this study is to present
results that could help the dental community
understand the factors associated with parents’
perceptions of their child’s oral health. According
to previous authors (15–17), these perceptions are
influenced by clinical and socioeconomic condi-
tions. It is a well-established fact that people from
low socioeconomic backgrounds are more likely to
Table 2. Prevalence of parents that rated their child’s oral health as ‘poor’ and associated factors
Variables n+ (%)
Parent’s Perception of child’s oral health (‘poor’)
PRcrude (95% CI) P PRadjusted (95% CI) P
Sociodemographic characteristicsChild’s gender
Boys 41 (16.7) 1.00Girls 36 (17.2) 1.02 (0.68–1.54) 0.89
Child’s age (years)£2 25 (11.7) 1.00 – **3 23 (19.2) 1.64 (0.97–1.76) 0.06‡4 29 (24.4) 2.08 (1.28–3.39) <0.01
Child’s ethnicityWhite 54 (15.7) 1.00 **Black 23 (20.9) 1.33 (0.85–2.06) 0.20
Household income‡3 BMW 28 (11.6) 1.00 1.00<3 BMW 46 (22.8) 1.96 (1.27–3.01) <0.01 1.84 (1.19–2.84) 0.01
Mother’s schooling‡8 years 43 (13.5) 1.00 **<8 years 32 (25.) 1.83 (1.21–2.75) 0.01
Father’s schooling‡8 years 44 (15.1) 1.00<8 years 21 (17.2) 1.13 (0.70–1.83) 0.59
Mother’s occupationEmployed 36 (17.5) 1.00Unemployed 39 (16.2) 0.92 (0.61–1.40) 0.73
Father’s occupationEmployed 61 (16.0) 1.00Unemployed 4 (12.5) 0.78 (0.30–2.01) 0.60
Clinical statusSealing Lip
Adequate 56 (16.4) 1.00Inadequate 18 (19.3) 1.17 (0.72–1.90) 0.50
Anterior Open BiteWithout 38 (14.2) 1.00 1.00With 33 (23.9) 1.68 (1.10–2.55) 0.01 1.71 (1.13–2.59) 0.01
Dental cariesWithout 38 (10.9) 1.00 1.00With 39 (36.8) 3.36 (2.27–4.98) <0.01 2.52 (1.67–3.81) 0.00
Dental TraumaWithout 44 (14.6) 1.00 **With 30 (21.6) 1.47 (0.97–2.24) 0.06
BMW, Brazilian minimum wage; n+, number of parents that rated their child’s oral health as ‘poor’.**Variables not included in the final multiple model after the adjustment.
263
Caregiver’s perception of child’s oral health
be exposed to various risk factors that affect the
self-perception of their overall health and well-
being (28–30). For oral health, the same pattern has
been demonstrated (31–34). However, most of the
evidence comes from studies conducted on adult or
adolescent populations. Therefore, the aim of this
study was to assess this association in preschool
children, using their parents’ perceptions as a
proxy. In Brazil, this is the first study that reports
the factors associated with caregivers’ perceptions
of children’s oral health.
According to Table 2, parents with lower house-
hold incomes were more likely to rate their child’s
oral health as ‘poor’ than their counterparts. This
confirms the findings that people who have a lower
socioeconomic status were more likely to rate their
oral health as poor, when compared to those who
have a higher status (12, 23). These social dispar-
ities remained strongly associated with the out-
comes even after the control of other variables.
Previous studies have suggested that socioeco-
nomic inequalities are associated with different
health outcomes (35–38). Such inequities could
affect both the child’s and family’s well-being,
resulting in a negative impact on daily perfor-
mance and the quality of life owing to the under-
lying influence of psychosocial, environmental, and
material deprivation (17, 39).
Table 3. Prevalence of parents that rated their child’s oral health as ‘‘worst than other children’’ and associated factors
Variables n+ (%)
Parent’s Perception of child’s oral health (‘worst than other children’)
PRcrude (95% CI) P PRadjusted (95% CI) P
Sociodemographic characteristicsChild’s gender
Boys 12 (5.0) 1.00Girls 8 (3.9) 0.77 (0.32–1.86) 0.57
Child’s age (years)£2 6 (2.9) 1.00 – **3 7 (5.9) 2.05 (0.71–5.98) 0.18‡4 7 (5.9) 2.03 (0.70–5.93) 0.19
Child’s ethnicityWhite 8 (2.4) 1.00 – 1.00Black 12 (11.1) 4.69 (1.96–11.19) <0.01 3.61 (1.51–8.66) 0.01
Household income‡3 BMW 10 (4.3) 1.00<3 BMW 10 (5.0) 1.17 (0.49–2.76) 0.71
Mother’s schooling‡8 years 13 (4.2) 1.00<8 years 6 (4.7) 1.10 (0.42–2.85) 0.83
Father’s schooling‡8 years 9 (3.2) 10<8 years 4 (3.3) 1.04 (0.32–3.32) 0.94
Mother’s occupationEmployed 13 (6.4) 1.00 **Unemployed 6 (2.5) 0.39 (0.15–1.03) 0.05
Father’s occupationEmployed 13 (3.4) 1.00Unemployed 2 (6.4) 1.85 (0.43–7.87) 0.40
Clinical statusSealing Lip
Adequate 11 (3.3) 1.00 **Inadequate 8 (8.8) 2.67 (1.10–6.46) 0.03
Anterior Open BiteWithout 7 (2.7) 1.00 1.00With 11 (7.8) 2.97 (1.17–7.50) 0.02 2.76 (1.14–6.69) 0.02
Dental cariesWithout 7 (2.0) 1.00 1.00With 13 (12.1) 5.88 (2.40–14.38) <0.01 4.39 (1.76–10.95) <0.01
Dental TraumaWithout 12 (4.0) 1.00With 7 (5.1) 1.25 (0.50–3.12) 0.62
BMW, Brazilian minimum wage; n+, number of parents that rated their child’s oral health as ‘worst than other children’.**Variables not included in the final multiple model after the adjustment.
264
Piovesan et al.
It was also found that caregivers’ perceptions of
children’s oral health were associated with clinical
variables (Table 2). Children with dental caries and
anterior open bite were more likely to have their
oral health rated as ‘poor’ when compared with
their counterparts.
Our findings confirmed the relationships re-
ported in previous studies between caregivers’
perceptions of children’s oral health and dental
caries (15, 16). It has been demonstrated that the
presence of untreated dental caries in the children
is associated with the parents’ perception that their
child’s oral health is poorer, irrespective of their
socioeconomic status (40, 41). For instance, in a
previous study (15), the caregiver’s perceptions
were significantly associated with the children’s
mean number of ‘cavitated’ carious lesions. The
authors found that from among those who
reported their children’s oral health status as being
‘poor’, the mean number of untreated ‘cavitated’
lesions was approximately 81 times higher than
that of the ‘excellent’ group (15). Children with
caries cavities are more likely to experience dental
pain and chewing difficulties. They are also more
likely to have been worried or upset about their
oral health status. This may influence the parent’s
perceptions of their child’s oral health (15, 16).
The image of satisfaction expressed by parents
with regard to their child could also explain the
association between anterior open bite and the
outcome (42). Previous investigations suggested
that malocclusion had a significant impact on the
oral health–related quality of life (14, 34, 43). The
primary impact of malocclusion on the quality of
life has been reported in the emotional and social
well-being domains, which comprise issues related
to esthetic components. This suggests that the most
significant impact of malocclusion on the quality of
life is because of the psychosocial features rather
than oral or functional problems (34, 44).
The prevalence of the parents who rated their
child’s oral health as ‘worse than that of the other
children’ was associated with ethnic and other
clinical variables (Table 3). Studies with the aim
of assessing the impact of race ⁄ ethnicity on care-
givers’ perceptions of children’s oral health in
preschool children are scarce. This influence is
complex and appears to be directly related to
biologic, socioeconomic, behavioral, and psychoso-
cial factors (45). The historical exclusion to which
certain groups have been exposed may
explain their predisposition to rate their oral health
as worse than that of their peers. It has been
demonstrated that children from racial ⁄ ethnic
minorities have higher levels of dental disease
(38). Dietrich et al. (46) found significant racial ⁄ eth-
nic disparities in US parent’s perceptions of the
oral health of their children. They found that the
parents of both Hispanic and non-Hispanic black
children rated their children’s oral health as being
worse-off than that of white children. The results of
the present study are consistent with those of
previous studies that found parents from minority
groups and those with greater poverty levels more
likely to rate their children’s oral health as ‘poor’
(16, 47, 48). Findings from previous studies suggest
that there is an association between race and
socioeconomic status. Socioeconomic factors can
interact with social characteristics, such as
race ⁄ ethnicity, to produce different health effects
across groups (49–51). One could argue that the
effect of race on the parents’ perceptions is depen-
dent on the socioeconomic status. However, the
impact of deprivation on minority ethnic groups
remained strongly associated with the outcome
even after the adjustment for confounders.
Although the role of socioeconomic and clinical
factors on the perceptions of parents with regard to
their child’s oral health are important from a public
health perspective, the results presented here must
be considered with caution.
The present study has two primary limitations
that could affect the interpretation of the results.
First, this study followed a cross-sectional design,
which prevents a hypothesis of causality and
temporal relations between the outcome and pre-
dictor variables. Studies using a longitudinal
design could provide a better understanding of
the factors influencing the caregivers’ perceptions
of children’s oral health. Second, one could argue
that the authors did not use a validated question-
naire to measure the children’s oral health–related
quality of life (COHRQoL). A few instruments used
for measuring COHRQoL in preschool children,
which include Parental Caregiver Perception, are
presently available (52–54). Moreover, no validated
instruments were available for Brazilian preschool
children when the present study was conducted.
However, the lack of information regarding
COHRQoL should not be considered a great bias
of this study, because the primary objective of the
latter was to investigate the predictors for parents’
perceptions of their child’s oral health using a
feasible instrument that the respondents would
find easy to manage. Furthermore, studies have
shown that the single-item perceived oral health
265
Caregiver’s perception of child’s oral health
rating is related to other self-reported measures of
oral health, such as multi-item indicators (55).
Thus, a single-item rating of perceived oral health
is particularly appropriate to obtain information
from children’s parents.
The parents’ perspectives are different from
those of the children. Depending on the type of
information sought in the questionnaire, the
reports of parents tend to be more or less accurate
than those of the children. It has been demon-
strated that parents are better able to assess the
areas related to function and physical symptoms
than those related to emotional and social functions
(14). However, very young children are unable to
complete the questionnaire by themselves. There-
fore, the use of proxy judgments regarding chil-
dren’s oral health should be considered a feasible
option to assess the children’s sociodental indica-
tors. Nevertheless, parents maintain accurate
assessments of their children’s oral health status,
which could result in accurate information for the
allocation of resources for dental health services
(16).
This study has resulted in new information from
a clinical and public health perspective. A repre-
sentative sample of preschool children in Brazil
was used, obtained by a random selection process
at different sample centers around the city. This
random process avoided a bias that might occur if,
for example, the sample were collected in a clinical
setting. Nevertheless, such a process provides
sound conclusions about the research question for
all preschoolers living in Santa Maria.
The present study suggests that parents’ percep-
tions of their child’s oral health are strongly
influenced by clinical and socioeconomic condi-
tions. Studies on the predictors of these perceptions
are important in health planning by the health
police and the promotion of oral health for the
target population. This is properly described when
considering that clinical measurements of oral
disease have a limited view of the children’s needs
(7, 9). It has been proposed that the planning of a
preventive strategy should take into account the
patients’ perceptions of needs. The perception of
health may reflect the expectations of oral health
relative to a reference groups. Ethnic and socioeco-
nomic differences may have an important influence
on the parents’ perceptions of their child’s oral
health. The findings that parents from ethnic and
socioeconomic minority groups currently have
more pessimistic views of their children’s oral
health may have important implications on the
health policy. Investment in such programs must
include components that determine the perceived
needs of the individuals, rather than a mere
straightforward attempt to combat dental disease.
Therefore, the results presented here, regarding the
caregivers’ perceptions of children’s oral health,
could be used to assess the needs, prioritize the
care, and evaluate the outcomes of treatment
strategies and initiatives in health care.
References1. Lawrence HP, Thomson WM, Broadbent JM, Poulton R.
Oral health-related quality of life in a birth cohort of 32-year olds. Community Dent Oral Epidemiol2008;36:305–16.
2. Zhang M, McGrath C, Hagg U. Orthodontic treatmentneed and oral health-related quality among children.Community Dent Health 2009;26:58–61.
3. Cohen LK, Jago JD. Toward the formulation of socio-dental indicators. Int J Health Serv 1976;6:681–98.
4. Locker D. An introduction to behavioural science edentistry. London: Tavistock; 1989.
5. Slade G. Measuring oral health and quality of life.Chapel Hill: University of North Carolina, DentalEcology; 1997.
6. Smith JM, Sheiham A. How dental conditions handicapthe elderly. Community Dent Oral Epidemiol1979;7:305–10.
7. Gherunpong S, Tsakos G, Sheiham A. Developing andevaluating an oral health-related quality of life index forchildren; the CHILD-OIDP. Community Dent Health2004;21:161–9.
8. Gherunpong S, Tsakos G, Sheiham A. The prevalenceand severity of oral impacts on daily performances inThai primary school children. Health Qual Life Out-comes 2004;2:57.
9. Locker D. Measuring oral health: a conceptual frame-work. Community Dent Health 1988;5:3–18.
10. Atchison KA, Gift HC. Perceived oral health in a diversesample. Adv Dent Res 1997;11:272–80.
11. Matthias RE, Atchison KA, Lubben JE, De Jong F,Schweitzer SO. Factors affecting self-ratingsof oral health. J Public Health Dent 1995;55:197–204.
12. Perera I, Ekanayake L. Factors influencing perception oforal health among adolescents in Sri Lanka. Int Dent J2008;58:349–55.
13. Wilson-Genderson M, Broder HL, Phillips C. Concor-dance between caregiver and child reports of children’soral health-related quality of life. Community Dent OralEpidemiol 2007;35:32–40.
14. Jokovic A, Locker D, Guyatt G. How well do parentsknow their children? Implications for proxy reporting ofchild health-related quality of life. Qual Life Res2004;13:1297–307.
15. Sohn W, Taichman LS, Ismail AI, Reisine S. Caregiver’sperception of child’s oral health status among low-income African Americans. Pediatr Dent 2008;30:480–7.
16. Talekar BS, Rozier RG, Slade GD, Ennett ST. Parentalperceptions of their preschool-aged children’s oralhealth. J Am Dent Assoc 2005;136:364–72.
17. Wandera M, Kayondo J, Engebretsen IM, Okullo I,Astrom AN. Factors associated with caregivers’ percep-tion of children’s health and oral health status: a studyof 6- to 36-month-olds in Uganda. Int J Paediatr Dent2009;19:251–62.
266
Piovesan et al.
18. Kawachi I, Subramanian SV, Almeida-Filho N. A glos-sary for health inequalities. J Epidemiol CommunityHealth 2002;56:647–52.
19. White K. An introduction to the sociology of health andillness. London: Sage Publications; 2002.
20. Elstad J. The psycho-social perspective on socialinequalities in health. Sociol Health Illn 1998;20:598–618.
21. Ellaway A, Macintyre S. Does housing tenure predicthealth in the UK because it exposes people to differentlevels of housing related hazards in the home or itssurroundings? Health Place 1998;4:141–50.
22. Martins AM, Barreto SM, Pordeus IA. Objective andsubjective factors related to self-rated oral health amongthe elderly. Cad Saude Publica 2009;25:421–35.
23. Matos DL, Lima-Costa MF. Self-rated oral health amongBrazilian adults and older adults in Southeast Brazil:results from the SB-Brasil Project, 2003. Cad SaudePublica 2006;22:1699–707.
24. Pattussi MP, Olinto MT, Hardy R, Sheiham A. Clinical,social and psychosocial factors associated with self-rated oral health in Brazilian adolescents. CommunityDent Oral Epidemiol 2007;35:377–86.
25. WHO. Oral health surveys: basic methods, 4th edn.Geneva: WHO; 1997.
26. O’Brien M. Children’s dental health in the UnitedKingdom 1993. London: Her Majesty’s Stationery Office;1994.
27. IBGE. Instituto Brasileiro de Geografia e Estatıstica.Pesquisa Nacional por Amostra de Domicılios: Sıntesede Indicadores; 2003 [updated 2009 November 6; cited2010 April 9]. Available from: http://www.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad2003/sintesepnad2003.pdf.
28. Gaspar T, Ribeiro JL, Matos MG, Leal I, Ferreira A.Psychometric properties of a brief version of the Escala deSatisfacao com o Suporte Social for children and adoles-cents. Span J Psychol 2009;12:360–72.
29. Hamilton AS, Hofer TP, Hawley ST, Morrell D, Leven-thal M, Deapen D et al. Latinas and Breast CancerOutcomes: Population-Based Sampling, Ethnic Identity,and Acculturation Assessment. Cancer Epidemiol Bio-markers Prev 2009;18:2022–9.
30. Skodova Z, Nagyova I, van Dijk JP, Sudzinova A,Vargova H, Rosenberger J et al. Socioeconomic inequal-ities in quality of life and psychological outcomes amongcardiac patients. Int J Public Health 2009;54:233–40.
31. Locker D. Disparities in oral health-related quality of lifein a population of Canadian children. Community DentOral Epidemiol 2007;35:348–56.
32. John MT, Koepsell TD, Hujoel P, Miglioretti DL,LeResche L, Micheelis W. Demographic factors, den-ture status and oral health-related quality of life.Community Dent Oral Epidemiol 2004;32:125–32.
33. Mandall NA, McCord JF, Blinkhorn AS, WorthingtonHV, O’Brien KD. Perceived aesthetic impact of maloc-clusion and oral self-perceptions in 14–15-year-oldAsian and Caucasian children in greater Manchester.Eur J Orthod 2000;22:175–83.
34. O’Brien C, Benson PE, Marshman Z. Evaluation of aquality of life measure for children with malocclusion. JOrthod 2007;34:185–93.
35. Antunes JL, Jahn GM, de Camargo MA. Increasinginequalities in the distribution of dental caries in theBrazilian context in Finland. Community Dent Health2005;22:94–100.
36. Antunes JL, Pegoretti T, de Andrade FP, Junqueira SR,Frazao P, Narvai PC. Ethnic disparities in the prevalence
of dental caries and restorative dental treatment inBrazilian children. Int Dent J 2003;53:7–12.
37. Levin KA, Davies CA, Topping GV, Assaf AV, Pitts NB.Inequalities in dental caries of 5-year-old children inScotland, 1993–2003. Eur J Public Health 2009;19:337–42.
38. Vargas CM, Crall JJ, Schneider DA. Sociodemographicdistribution of pediatric dental caries: NHANES III,1988–1994. J Am Dent Assoc 1998;129:1229–38.
39. Sabbah W, Tsakos G, Sheiham A, Watt RG. The role ofhealth-related behaviors in the socioeconomic dispari-ties in oral health. Soc Sci Med 2009;68:298–303.
40. Cushing AM, Sheiham A, Maizels J. Developing socio-dental indicators – the social impact of dental disease.Community Dent Health 1986;3:3–17.
41. Reisine ST, Bailit HL. Clinical oral health status andadult perceptions of oral health. Soc Sci Med MedPsychol Med Sociol 1980;14:597–605.
42. Reisine S. An overview of self-reported outcome assess-ment in dental research. J Dent Educ 1996;60:488–93.
43. Johal A, Cheung MY, Marcene W. The impact of twodifferent malocclusion traits on quality of life. Br Dent J2007;202:E2.
44. O’Brien K, Wright JL, Conboy F, Macfarlane T, MandallN. The child perception questionnaire is valid formalocclusions in the United Kingdom. Am J OrthodDentofacial Orthop 2006;129:536–40.
45. Thumboo J, Fong KY, Machin D, Chan SP, Soh CH,Leong KH et al. Quality of life in an urban Asianpopulation: the impact of ethnicity and socio-economicstatus. Soc Sci Med 2003;56:1761–72.
46. Dietrich T, Culler C, Garcia RI, Henshaw MM. Racialand ethnic disparities in children’s oral health: theNational Survey of Children’s Health. J Am Dent Assoc2008;139:1507–17.
47. Goodman HS, Macek MD, Wagner ML, Manz MC,Marrazzo ID. Self-reported awareness of unrestoreddental caries. Survey of the Oral Health Status ofMaryland Schoolchildren, 2000–2001. Pediatr Dent2004;26:369–75.
48. Vargas CM, Ronzio CR. Relationship between children’sdental needs and dental care utilization: United States,1988–1994. Am J Public Health 2002;92:1816–21.
49. Barbeau EM, Krieger N, Soobader MJ. Working classmatters: socioeconomic disadvantage, race ⁄ ethnicity,gender, and smoking in NHIS 2000. Am J Public Health2004;94:269–78.
50. Braveman PA, Cubbin C, Egerter S, Chideya S, MarchiKS, Metzler M et al. Socioeconomic status in healthresearch: one size does not fit all. JAMA 2005;294:2879–88.
51. Marmot M, Ryff CD, Bumpass LL, Shipley M, MarksNF. Social inequalities in health: next questions andconverging evidence. Soc Sci Med 1997;44:901–10.
52. Li S, Veronneau J, Allison PJ. Validation of a Frenchlanguage version of the Early Childhood Oral HealthImpact Scale (ECOHIS). Health Qual Life Outcomes2008;6:9.
53. Pahel BT, Rozier RG, Slade GD. Parental perceptions ofchildren’s oral health: the Early Childhood Oral HealthImpact Scale (ECOHIS). Health Qual Life Outcomes2007;5:6.
54. Tesch FC, Oliveira BH, Leao A. Semantic equivalence ofthe Brazilian version of the Early Childhood Oral HealthImpact Scale. Cad Saude Publica 2008;24:1897–909.
55. Atchison KA, Dolan TA. Development of the GeriatricOral Health Assessment Index. J Dent Educ 1990;54:680–7.
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Caregiver’s perception of child’s oral health
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