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Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 164-170

Does maternal tooth brushing-related sef-efficacy predict child's brushing adherence?

Department of Pedodontics and Preventive Dentistry, DY Patil University-School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Submission27-Aug-2020
Date of Decision22-Jun-2021
Date of Acceptance03-Jul-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Uma B Dixit
Smiling Stars Dental Clinic for Children Zaver Road, Mulund West 400080, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_370_20

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Background: Dental plaque is a root cause of dental caries. Effective plaque control in young children can be achieved with twice-daily assisted tooth brushing. Self-efficacy relates to one's confidence in performing a task. Self-efficacy is shown to facilitate the behavior change in treatments for lifestyle diseases. The influence of maternal self-efficacy in children's oral health behaviors is less studied. Aim: The aim of this study is to evaluate an association between maternal tooth brushing-related self-efficacy (MTBSE) and child's brushing adherence. Settings and Design: This cross-sectional study was conducted in schools and included 781 mother-child dyads with children between the age group of 2 and 6 years. Methods: Selected mothers were asked to complete the questionnaires on sociodemographic data, mother's oral health knowledge (MOHK), tooth-brushing practices, and MTBSE. Brushing adherence was evaluated as complete adherence if the child followed twice daily assisted brushing using the toothbrush and toothpaste. Statistical Analysis: Nonparametric tests were used to compare the variables. Binary logistic regression was used to evaluate the predictors of brushing adherence. Results: Complete brushing adherence (assisted brushing with toothbrush and toothpaste at least twice per day) was seen only in 26.9% children. More children with complete brushing adherence were single children (P < 0.001). Children with complete brushing adherence had mothers with significantly higher MTBSE (P < 0.001). The presence/absence of siblings, MOHK, and MTBSE were found to be strong and significant predictors of brushing adherence in children. Conclusions: MTBSE plays a significant role in complete adherence to toothbrushing in children aged 2–6 years.

Keywords: Mothers, oral health, self efficacy, siblings, toothbrushing

How to cite this article:
Dixit UB, Sehgal PR, Moorthy L, Iyer H. Does maternal tooth brushing-related sef-efficacy predict child's brushing adherence?. J Indian Soc Pedod Prev Dent 2021;39:164-70

How to cite this URL:
Dixit UB, Sehgal PR, Moorthy L, Iyer H. Does maternal tooth brushing-related sef-efficacy predict child's brushing adherence?. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Aug 11];39:164-70. Available from: http://www.jisppd.com/text.asp?2021/39/2/164/322508

   Introduction Top

Dental plaque is a root cause of oral diseases such as caries and gingivitis. Toothbrushing is an effective measure to control plaque and to ensure good oral health. It is recommended that in children brushing should be started with the eruption of the first tooth and the practice of toothbrushing should be performed twice daily, using a soft toothbrush with an age-appropriate amount of fluoridated toothpaste.[1] For young children, since they lack the seriousness, motivation, and dexterity to implement appropriate toothbrushing, parents need to assist in brushing until the children are 6 years of age.[2] Brushing frequency of twice or more per day as recommended is shown to reduce the odds of having caries in young children between 1 and ½ and 4 and ½ years of age.[3] Parents' ability to exercise control over toothbrushing in young children is associated with a low caries experience in children.[4]

Mothers play an important role in inculcating good oral health habits in their children, since mothers are the primary caregivers for young children.[5] Parental knowledge and attitude regarding oral hygiene care and oral disease are associated with oral hygiene habits in their children.[4] However, only having oral-health-related knowledge has never been found to motivate parents to institute proper oral health behavior in their children. It was reported by Blinkhorn et al.[6] that although 71% of mothers of high-risk preschool children were aware of the need for daily-supervised toothbrushing, only 40% practiced it.

This paradox may be explained with the help of Bandura's social cognitive theory, according to which, self-efficacy beliefs determine human behavior.[7] In addition to having the task-related knowledge and skills, an individual must have the conviction of performing the required behavior under typical and importantly, under challenging circumstances. Bandura defined self-efficacy as individuals' judgments of their capabilities to organize and execute the courses of action required to attain designated types of performances.[8]

When applied to the clinical setting, self-efficacy refers to a person's perception of his or her ability to perform the actions needed to improve and maintain health.[9] The role of self-efficacy in facilitating behavioral change has been explored in the treatment of addictions,[10],[11] obesity management,[12],[13] and management of diabetes.[14],[15]

Few studies have explored the relationship between maternal self-efficacy and oral health-related behavior in young children. In a cross-sectional study consisting of 100 mother-child dyads, Wilson et al.[16] found a significant association among maternal oral health knowledge, higher perceived benefits, and increased self-efficacy. A similar finding was reported by Soltani et al.[5] Finlayson et al.[17] studied 1021 African–American mother-child dyads and found that maternal oral hygiene self-efficacy (OHSE) was a strong and significant predictor of the children's brushing frequency. However, they did not consider assisted brushing, which might be influenced more by maternal self-efficacy.

As cultural differences influence self-efficacy[18] and since there are no studies published from India regarding maternal self-efficacy and young children's toothbrushing practices, we believed that such a study would add to the current knowledge. The purpose of this study was to evaluate an association of maternal tooth brushing-related self-efficacy (MTBSE) with a child's brushing adherence.

   Methods Top

Study design and sample size calculation

The Institutional Ethical Committee approved this cross-sectional study, which complied with the declaration of Helsinki (2000) and good clinical practice guidelines. A pilot study was conducted on 30 mother-child dyads. The sample size was determined according to the proportions available from the pilot study in a single proportion test. As 60% of the mothers in the pilot study had high oral hygiene-related self-efficacy, a sample size of 726 provided a power of 80% at alpha = 0.05 (95% confidence level) was estimated.


A cluster randomization method was used for the study. Mumbai and Navi Mumbai regions were divided in four clusters each depending on the location and two kindergarten schools having at least two classrooms per division were randomly selected from each of the clusters. Dates of birth of all children in kindergarten classes were obtained from the schools, and children between 2 and 6 years of age with complete primary dentition, without any permanent teeth, and with good systemic health were included in this study. Children, whose mothers were not available or who had significant illnesses that affected day-to-day functioning, were excluded. Informed consents were obtained from the mothers who agreed to participate in this study along with their children.


Sociodemographic data

This questionnaire included a total of 11 questions, including child's date of birth and gender, presence of siblings, child's birth order, mother's date of birth, educational qualification, and occupation. Some of the questions such as “can you read and write English?,” child's mother tongue and religion were included to communicate better with the dyads and confirm if the mothers could respond to the questionnaires effectively.

Mother's oral health knowledge

A set of nine questions were prepared to assess the mother's basic oral health knowledge. Questions such as “Do you think milk teeth are important?,” “Can problems of the primary teeth affect the permanent teeth?,” “Does regular brushing prevent dental problems?,” and “Is the practice of tongue cleaning and postmeal rinsing important?” were included. Each of these questions had three optional answers: Yes, no, or don't know. Responses of “no” and “don't know” were assigned a score 0; “yes” was assigned a score of 1.

Questions such as “When should you begin brushing your child's teeth?,” “How many times should brushing be done?,” “Until what age should the child be assisted in brushing?” and “What is used for cleaning the child's teeth?” were also included in the questionnaire. Each of these questions was provided with multiple answers. A correct response was scored as 1, and all other (i.e., wrong) answers were scored as 0. The scores thus obtained for each question were then added to obtain a total score of mother's oral health knowledge (MOHK), which ranged from 0 to 9.

Maternal toothbrushing-related self-efficacy

The scale measured the mother's self-confidence to perform toothbrushing for her child under difficult circumstances such as feeling extremely tired, stressed from work, busy with guests at home, on a family vacation, and feeling ill. Mothers were asked to rate their confidence level on a 4-point Likert scale ranging from 0= “not at all confident” to 3= “extremely confident,” so that the range of total scores was from 0 to 15. The higher the score, the better the toothbrushing-related self-efficacy.

Validity and reliability of questionnaires

The content validity of the OHK and MTBSE questionnaires was performed through an expert panel of seven pediatric dentists, each with minimum clinical experience of 5 years, who graded each question on a four-point Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant). The content validity ratios for MOHK and MTBSE were found to be 0.971 and 0.943, respectively, and content validity indices were found to be 0.986 and 0.97, respectively.

To assess the test-retest reliability of the MOHK and MTBSE questionnaires, prior to commencement of the study, 30 participants were asked to complete the questionnaires twice with an interval of 30 days. The collected data were subjected to the statistical analysis to calculate the Cronbach's alpha. The reliability of MOHK and MTBSE was 0.792 and 0.830, respectively. Higher values of Cronbach's alpha for both the questionnaires suggested good reliability.

Brushing adherence

Brushing adherence of a child was evaluated as a measure of following all age-appropriate guidelines regarding brushing.[1] Information was obtained from mothers regarding three brushing-related practices of their child, namely brushing frequency (appropriate: two or more times per day), brushing assistance (appropriate: adult-assisted), and the tooth cleaning aid (appropriate: toothbrush and toothpaste). Specific information regarding the use of fluoridated or nonfluoridated toothpaste was not recorded.

A participant who reported following all three appropriate practices regarding toothbrushing for her child was considered to adhere completely to the brushing protocol and was given a score of 1. A participant who did not follow one or more of the above-mentioned appropriate brushing-related practices was considered as not adhering to the brushing protocol and was assigned a score of 0. Brushing adherence was determined as the primary outcome of this study.

Statistical analysis

The collected data were analyzed using the SPSS software version 24.0 (SPSS Inc., Chicago, IL, USA). The Shapiro–Wilk test was used to test the normality of the continuous variables. Since the data showed nonnormal distribution, nonparametric test such as the Mann–Whitney U test was used to compare the continuous variables. The Chi-square test was used to compare the categorical variables between the two levels of brushing adherence (no adherence and complete adherence). Binary logistic regression was employed to evaluate the ability of the independent variables to predict the dependent variable (brushing adherence).

   Results Top

For this cross-sectional study, a total of 1365 mother-child dyads were selected [Figure 1], out of which 584 (42.8%) dyads were excluded due to various reasons such as refusing to participate (146, 10.7%), not fulfilling selection criteria (48, 3.5%), and returning incomplete questionnaires (390, 28.6%). Finally, 781 mother-child dyads were included in this study.
Figure 1: Flow chart of selection of participants

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Demographic characteristics of the total sample are presented in [Table 1]. The sample included 427 male and 354 female children with a mean age of 50.2 months (range, 25–71 months). The mean age of the mothers was 31.6 years, with most having education in the form of some college and a graduate or postgraduate degree (74.8%). Most mothers were homemakers (64.9%). The mean MOHK score of the total sample of mothers was found to be 6.6 ± 1.6 (range, 1–9). Mean of MTBSE was 9.5, with a range between 0 and 15.
Table 1: Characteristics of the total sample

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Out of 781 dyads, 210 (26.9%) showed complete adherence and 571 (73.1%) showed no adherence to brushing protocol, for which comparative analysis is presented in [Table 2]. More children with complete brushing adherence were single children with no siblings. This association was statistically significant (P < 0.001) with very small effect size (V = 0.13). Although mothers of children showing complete brushing adherence had higher MOHK than those with children with no adherence, this difference did not reach statistical significance (P = 0.13, r = 0.06). In children with complete adherence to brushing protocol, MTBSE was significantly higher compared with those with no adherence to brushing protocol (P < 0.001), effect size being small (r = 0.17).
Table 2: Comparison of variables between the two levels of brushing adherence: no adherence, complete adherence

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Since there were no outliers, all 781 children entered the step-wise regression analysis. Overall, model fit was found to be statistically significant (χ2 = 70.49, P < 0.001), indicating that one or more of the independent variables contributed to the prediction of the outcome variable (brushing adherence). This model explained 12.6% of variance for observed lack of adherence to brushing in children (Negelkerke R2= 0.126). The classification accuracy rates were 96.9% for no brushing adherence and 12.9% for complete brushing adherence.

Of all the variables entered, the presence of siblings (β = −0.44, P = 0.009), MOHK (β =0.30, P = 0.0001), and MTBSE (β =0.067, P = 0.004) were found to be significant predictors of the brushing adherence in children [Table 3]. Odds of complete adherence to brushing in children were higher in the dyads with higher MOHK (odds ratio [OR] =1.36, 95% confidence interval [CI]: 1.17–1.58) and higher MTBSE (OR = 1.07, 95% CI: 1.02–1.12). Having siblings and mothers with less education decreased the odds of complete brushing adherence in children by 37% and 10%, respectively.
Table 3: Factors predicting children's complete adherence to brushing protocol

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   Discussion Top

The uniqueness of our study is our primary outcome: Brushing adherence to the age-appropriate brushing recommendations: Assisted brushing with toothbrush and toothpaste at least two times per day. Earlier studies on brushing behavior in children or adults have mostly used brushing frequency either as a dichotomized categorical outcome (twice or less[19]) or a continuous variable (number of brushing incidences per week[16]).

The mere frequency of toothbrushing cannot be considered a measure of effective plaque removal. Young children do not have the dexterity to clean their teeth sufficiently on their own.[20] It is recommended that, for effective plaque removal, an adult should assist a young child in brushing. Thus, all three factors – assisted brushing, use of toothbrush and toothpaste, and frequency – were considered in our primary outcome as brushing adherence. This outcome minimized over-estimation of reported brushing behavior and closely reflected the quality of oral hygiene maintenance.

It must be noted here that one of the age-appropriate recommendations include brushing with a fluoridated toothpaste. However, we did not include it in our primary outcome of brushing adherence for two reasons: (1) Inability to collect the accurate data as most parents are not aware if the toothpaste used by them contains fluoride,[21] (2) children's caries status or experience was not one of the outcomes in this study.

We were interested in the younger age group since most lifestyle-related habits are established at a younger age. Since young children depend on adults, especially their mothers, for initiation and completion of routine tasks, including oral hygiene measures such as brushing,[22] factors that motivate mothers to conduct these tasks (even in a state of aversive arousal) play an important role. We studied MTBSE as a link between recognizing the need for and actual performance of toothbrushing in their children.

Our results clearly demonstrated that children who adhered to brushing completely had mothers with significantly higher MTBSE and also showed significant association with having no siblings. MTBSE and presence or absence of siblings along with MOHK were the strong and significant predictors of complete brushing adherence in children.

The literature is diverse on the association of maternal oral health knowledge and a child's oral health behavior. In a study to investigate maternal oral health knowledge and attitude on child's brushing practices and oral health status, no association was found between the oral health knowledge and twice-daily toothbrushing. The authors also reported an OR of 0.4 for maternal oral health knowledge in predicting sound dentition in children, indicating that children of mothers with high oral health knowledge score were 60% less likely to have sound dentition.[23] Alkhtib and Morawala[24] reported that despite mothers having good oral health knowledge, their children had poor oral health practices, suggesting that knowledge was not translated into good practices for the child.

A simplistic relationship may not be assumed between oral health knowledge and oral health behavior. There are many factors, such as self-efficacy, that may mediate changes in the oral health behavior. In their study, Lee et al.[25] claimed that oral health literacy might confer its effect on oral health status through self-efficacy.

In the view of an ambiguous role of oral health knowledge in oral health behavior, our findings of positive influence of MTBSE on brushing adherence in children are significant. An earlier study by Finlayson et al.[17] also reported that maternal OHSE was a strong and significant predictor of children's brushing frequency; for each unit increase in OHSE, 1 to 3 year olds were expected to brush 18% more frequently on average for a week, and 4 and 5 year olds were expected to brush 9% more often.

Wilson et al.[16] reported that mothers who had high knowledge perceived that there were greater benefits from adherence with recommended oral health behavior and had greater confidence in their ability to manage their children's oral health. Soltani et al.[5] found both oral health knowledge and maternal self-efficacy to be strong predictors of brushing behavior in children between 2 and 6 years of age. de Silva-Saigorski et al.[26] reported similar results where the parents with the highest tertile for self-efficacy were three times more likely to report that their child brushed their teeth at least twice a day compared with those parents who were in the lowest tertile for self-efficacy.

We found that having siblings decreased the odds of adhering to a brushing protocol in children by 37%. This finding was not unexpected, since parents with more than one child have to distribute their time among their children. Increased demands on parents may cause avoidance behavior. Earlier studies reported that children with more siblings were at risk of developing caries due to divided attention of parents between/among their children.[27],[28]

Most health education models are based on the assumption that increasing a patient's knowledge will promote better health-related behavior. Self-efficacy, however, should be the focus. Few studies in adults have shown promising results of increasing oral-health-related behaviors with the use of interventions to increase self-efficacy.[29],[30] Preventive programs for oral diseases in children should focus on increasing oral-health-related self-efficacy in mothers, to facilitate alteration in oral disease-causing behaviors in the children.


Some limitations of our study should be noted. The findings of this study may be generalized with caution for population at large due to the variability in sociodemographic and cultural characteristics of the population. The nature of our study is cross-sectional, and findings should be viewed with some caution. More longitudinal interventional studies should be conducted to confirm our findings.

In our study, the questionnaire was self-reported by the mothers, so there is a probability that the mothers could have misunderstood certain questions or overestimated their confidence in performing toothbrushing in difficult situations in the presence of the trained investigators. However, a larger sample size in our study would have minimized this probability.

   Conclusions Top

This is the first study that has introduced “brushing adherence” as an outcome that includes adherence to age-appropriate recommendations, namely assisted brushing with toothbrush and toothpaste at least two times per day. Children who adhered to brushing had mothers with higher tooth brushing-related self-efficacy and were mostly single children with no siblings. Maternal toothbrushing-related efficacy along with MOHK and presence/absence of siblings were found to be strong and significant predictors of complete brushing adherence in children between 2 and 6 years of age.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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[PUBMED]  [Full text]  
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