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Childrens use of dental services:influence of maternal dentalanxiety, attendance pattern, andperception of childrens qualityof lifeGoettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD. Chil-drens use of dental services: Influence of maternal dental anxiety, attendancepattern, and perception of childrens quality of life. Community Dent Oral Epi-demiol 2012; 40: 451458.2012 John Wiley & Sons A/S

Abstract Objectives :The purpose of the study was to investigate theinfluence of a childs clinical condition; maternal characteristics such as dentalanxiety and dental visit pattern; socioeconomic conditions; and maternalperception of the childs oral health-related quality of life (OHRQoL) on achilds use of dental care services.Methods :A cross-sectional study of 608motherchild dyads was conducted during the Childrens ImmunizationCampaign in Pelotas, Brazil. Mothers answered a questionnaire regarding theiruse of dental services, dental anxiety (Dental Anxiety Scale), socioeconomicstatus, and perception of their childrens OHRQoL (the Early Childhood OralHealth Impact Scale). Clinical examination of the children was performed to

assess dental caries (dmf-t). Associations between the above-mentioned factorsand child use of dental services were assessed using Poisson regression models(prevalence ratio [PR]; 95% CI;P 0.05).Results :The majority of children(79.3%) had never had a dental appointment and of the children who hadvisited a dentist, 55 (43.65%) presented with untreated dental caries at the timeof examination. More than half the mothers (60.2%) did not visit a dentistregularly. In the final model, low schooling level of mothers (PR, 0.64) andirregular visits to a dentist by the mother (PR, 0.48) were factors because ofwhich a child did not have a dental appointment. Children who hadexperienced pain (PR, 1.56), those who had poor OHRQoL (PR, 1.49), and olderchildren (PR, 2.14) visited a dentist with higher frequency. Conclusions :Use ofdental care services by preschool children was low, and treatment wasneglected even among children who had visited a dentist. Children of motherswith low schooling level who do not visit a dentist regularly were at greater

risk of not receiving dental care. Maternal perception of their childs oral healthmotivated visits to the dentist.

Marlia L. Goettems1, Thiago M.

Ardenghi2, Flavio F. Demarco3, Ana R.

Romano4 and Dione D. Torriani5

1Department of Social and PreventiveDentistry, School of Dentistry, FederalUniversity of Pelotas, Pelotas, Brazil,2Department of Stomatology, School ofDentistry, Federal University of Santa Maria,Santa Maria, Brazil, 3Department ofOperative Dentistry, School of Dentistry,Federal University of Pelotas, Pelotas, Brazil,4Department of Social and PreventiveDentistry, School of Dentistry, FederalUniversity of Pelotas, Pelotas, Brazil,5Department of Social and PreventiveDentistry, School of Dentistry, FederalUniversity of Pelotas, Pelotas, Brazil

Key words: dental care; health caredisparities; oral health; preschool children

Marlia Leao Goettems, Department of Socialand Preventive Dentistry, School ofDentistry, Federal University of Pelotas, RuaGoncalves Chaves, 457 Center 96015-560Pelotas, BrazilTel.: +55 53 32256741Fax: +55 53 32224162e-mail: [email protected]

Submitted 21 June 2011;accepted 7 March 2012

Despite the declining occurrence of dental caries, it

remains the pre-eminent oral disease of childhood.

Therefore, it is considered the primary marker of

childrens oral health, while visits to a dentist are

considered a marker of care (1). Oral health care

assistance can help develop healthy oral health

habits in preschool children to a large extent. It is

recommended that a childs first visit to a dentist

happen by the age of 1 year (2). This early visit

gives a dentist a chance to improve the childs oral

hygiene, to correct improper dietary habits, and to

improve parents knowledge. Regular visits to a

doi: 10.1111/j.1600-0528.2012.00694.x 451

Community Dent Oral Epidemiol 2012; 40: 451458All rights reserved

2012 John Wiley & Sons A/S


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dentist afford long-term benefits in terms of higher

subsequent use of preventive services and lower

dental care-related expenditure (3).

Dental care may also reduce inequalities in

dental health among children and compensate for

factors in the childs surroundings that could be

associated with poor dental health (4). Specific

behaviors have been identified as being associatedwith caries in preschool children. Most of these

oral health behaviors the dental team could

attempt to modify with appropriate advice to

parents when they attend for the treatment of their

children. (5)Therefore, it is important to under-

stand the dental visit pattern of children.

In Brazil, usually, only a small percentage of chil-

dren visit a dentist at the recommended age (6, 7).

Data from a national survey (PNAD) showed that

77.1% of children aged 06 years had never visited

a dentist; however, children with higher socioeco-

nomic statuses were five times more likely to havereceived dental care services than did children with

lower socioeconomic statuses (7). Similar findings

have been observed in other countries (8, 9). Edel-

stein et al. (1) assessed the trends in dental caries

and use of dental care services among American

children and found disparities in dental visits and

oral health according to age, family income, race/

ethnicity, and caregiver education level.

Characteristics such as low maternal schooling

level, family attendance patterns, and presence of a

healthcare system are frequently cited as barriersto dental care visits of children (7, 10, 11). Decisions

regarding oral health care and health-care utiliza-

tion patterns can also be influenced by the presence

of either normative or self-perceived oral health

care needs. However, despite the association of

psychosocial factors with the use of dental care ser-

vices in adults and older children, the influence of

psychosocial factors, such as parental perceptions

of the childs oral health (10) and dental anxiety, on

the use of dental services in preschool children (12)

is unclear. Parental characteristics, attitudes, and

perceptions may not only influence the parentsown use of dental services but also their childrens

use of dental services, because children depend on

their parents for visits to a dentist.

Therefore, this study aimed to assess the influ-

ence of childrens clinical condition; maternal char-

acteristics such as dental anxiety and use of dental

services; socioeconomic conditions; and maternal

perceptions of the childs oral health-related qual-

ity of life (OHRQoL) on a childs use of dental ser-

vices. The primary hypothesis to be tested was that

maternal dental anxiety, irregular attendance pat-

tern, and a negative perception of the childs OHR-

QoL were associated with childs use of dental care

services.

Materials and methods

Study population and sampling procedureA cross-sectional study consisting of children aged

25 years and their mothers was performed in the

city of Pelotas during the Childrens National

Immunization Campaign in June 2009. Pelotas is

located in southernmost Brazil and has about

350 000 inhabitants, including 22 150 children

aged 5 years or younger (13). According to the

Ministry of Health, acceptance of the immuniza-

tion program among children aged up to

59 months in Pelotas was 90%. Of these children,

only a small percentage (4%) was vaccinated inplaces other than public health centers, such as

schools or supermarkets.

To examine the association between the use of

dental services and the independent variables, we

used the following parameters on the basis of

parameters reported in a previous study (14): 5%

standard error, 80% power, 95% confidence inter-

val, 10% nonresponse, a 2:1 ratio of unexposed to

exposed, and a prevalence ratio to be detected of at

least 1.8. As cluster sample selection was used, a

design effect of 1.4 was estimated. The minimumsample size to satisfy the requirements was esti-

mated to be 456 children. However, as this study

was part of a larger study designed to assess the

prevalence of maternal dental anxiety (15), the

sample was increased to 507 motherchild dyads.

A two-stage stratified sample design was used to

select the sample. Of the 25 existing healthcare

centers in towns that have dental office facilities,

nine were randomly selected using a probability

selection method, with probability proportional to

the size of the health center. There was at least one

sampling point in each of the seven administrativeareas into which the city is divided. After the

children were vaccinated, mothers were invited to

participate in the survey, which included an inter-

view of the mother and a dental examination of the

child. Children with neurological or systemic

diseases were not included.

Data collectionTwelve previously trained dental students con-

ducted interviews with the mothers. Monthly

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family income was measured in terms of the Bra-

zilian minimum wage, which corresponded to

approximately 250 US$ at the time of data collec-

tion. Educational level was assessed by comparing

mothers who had completed more than 8 years of

formal education, which corresponds to primary

school education in Brazil, with those who had not.

Mothers were asked about their use of dentalservices and whether their children had ever had a

dental appointment. Maternal dental attendance

pattern was classified as nonregular if she

answered that she (1) never goes to the dentist or

(2) goes to the dentist when she feels pain or has a

problem; and regular if she answered that she (3)

goes to the dentist whether she has a problem or

not or (4) goes to the dentist regularly (16). Mater-

nal dental anxiety was measured using the Brazil-

ian version of Corahs Dental Anxiety Scale (DAS)

(17). It contains 4 multiple-choice items dealing

with subjective reactions to visiting the dentist andother dental-related situations. Each item was

scored on a scale from 1 (calm) to 5 (terrified). The

total score for all items ranged from 4 to 20. Moth-

ers dental anxiety was classified as low (DAS score

of 11 or less), moderate (DAS score from 12 to 14),

or high (DAS score of 15 or more) (18).

To assess maternal perceptions of their childrens

OHRQoL, the Brazilian version (19) of the Early

Childhood Oral Health Impact Scale (ECOHIS),

which was developed and validated by Pahel et al.

(20), was used. It consists of 13 items, including achild impact section and a family impact section.

Answers were recorded using a Likert scale, with

response options coded from 0 to 5 (0 = never,

1 =hardly ever, 2 =occasionally, 3 = often, 4 =very

often, and 5 = do not know). The total score ranged

from 0 to 52. Dont know responses were recorded

as missing. For those with up to two missing

responses in the child section or one in the family

section, a score for the missing items was imputed

as an average of the remaining items for that sec-

tion (20). ECOHIS scores were dichotomized using

the median value as a cut-off point. Detailed infor-mation of the impact on OHRQoL in this sample

has been reported elsewhere (15).

Clinical oral examinations were performed by 12

dentists, who were postgraduate students with

previous experience in administering oral health

surveys and who had been trained and calibrated

at the School of Dentistry of the Federal University

of Pelotas. Training practice was performed for a

4-h period. Then, each of the dentists examined

15 children with different levels of disease. Inter-

examiner agreement was tested against a gold

standard examiner. Intra-examiner reliability was

investigated by repeat examinations 1 week later

(21). Kappa statistics were used to test both inter-

and intra-examiner reliability. World Health Orga-

nization (WHO) (22) criteria, which do not include

initial noncavitated caries lesions, were used for

dental caries assessment. Dental examinations wereperformed at dental offices in healthcare centers

under artificial light by using a dental mirror and a

WHO periodontal probe. Biosafety principles

established by the WHO were followed (22). To test

the proposed methodology a pilot study involving

15 children was carried out prior to data collection.

Statistical analysesStatistical analyses were performed using Stata

version 10.0 (Stata Corporation, College Station,

TX, USA). Unadjusted analyses provided summary

statistics assessing the association between out-come and the independent variables. In the analy-

ses, the use of dental services (outcome) was

considered a dichotomous variable (never used

versus ever used). A Poisson regression model

with robust variance was used to assess the associ-

ation between the predictor variables and outcome.

This strategy allowed for the estimation of preva-

lence ratios (PR) between the comparison groups

and their respective 95% confidence interval (CI).

A forward stepwise procedure was used to include

or exclude explanatory variables in model fitting.Variables with P values of 0.20 in the assess-

ment of correlation (unadjusted analyses) were

included in the model fitting. For the final models,

the variables were considered significant if they

had a P value of 0.05 after adjustment. The

analyses took into account the clustered sample.

Ethical considerationsThis study was approved by the Human Research

Ethics Committee of the Federal University of

Pelotas. All the mothers gave written informed

consent. Mothers were informed of the oral healthstatus of their children, and the children who

needed dental treatment were referred to the

School of Dentistry.

Results

Inter-examiner Kappa values ranged from 0.85 to

0.96 (mean = 0.92), and the intra-examiner Kappa

value ranged from 0.70 to 1 (mean = 0.95).

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A total of 685 mothers were invited to participate

in the survey, and 92% of them agreed to partici-

pate. Of the 630 mothers who answered the ques-

tionnaire 3.5% (n = 22) were excluded from data

analysis because of the childs refusal during clini-

cal examination; therefore, a total of 608 mother

child dyads were included in the analysis.

The distribution of mothers and children accord-ing to demographics and family characteristics is

presented in Table 1. The majority of children

(79.3%) had never had a dental appointment, and

more than half of the mothers (60.2%) did not visit

a dentist regularly. The mean ages of the mothers

and children were 29.3 years (SE = 0.29) and

43.4 months (SE = 0.49), respectively. Thirty-nine

percent of the children had early childhood caries

(ECC), defined as the presence of one or more

decayed tooth surfaces in any primary tooth of

children younger than 72 months (23). Only 1.7%

of the children with dmft 1 had had restored orextracted teeth, and of the 126 children who had

visited a dentist at least once, 55 (43.65%)

presented with untreated dental caries at the time

of examination. Nearly half the mothers had a

moderate or high level of dental anxiety, ECOHIS

total scores ranged from 0 to 42 with a mean of 3.3

(SE = 0.22) and a median of 1. Three hundred and

fifty-eight mothers (58.9%) reported that their

children had impact in at least one item on the

ECOHIS.The number and proportion of children who vis-

ited a dentist according to the independent vari-

ables are shown in Table 2. In bivariate analyses,

probability of having had a dental appointment

was lower for children of low-income families (PR,

0.64; 95%CI 0.460.89) and whose mother had low

schooling level (PR, 0.58; 95%CI 0.430.80) and

irregular visits to a dentist (PR, 0.48; 95% CI 0.35

0.65) Children who had experienced pain (PR, 1.87;

95% CI 1.382.54), whose mothers had perceived

impact on the childs quality of life (PR, 1.71; 95%

CI 1.242.37) and older children (PR, 2.26; 95% CI1.383.71) visited a dentist with higher frequency.

In the multivariate analysis, the associations

between the childs use of dental services and

maternal attendance pattern, maternal schooling,

the childs age, the presence of pain and perception

of the childs OHRQoL were confirmed. Children

whose mothers did not visit a dentist regularly

were less likely (PR, 0.49) to have ever gone to the

dentist than their counterparts; this probability

was also lower (PR, 0.65) for children whose moth-

ers had lower levels of education than for thosewhose mothers had more than 8 years of formal

education. Children with mothers who reported

their childs OHRQoL as poor (below the sample

median) had a higher likelihood of having already

visited a dentist (PR, 1.49 1.052.13).

Discussion

This study assessed factors associated with 2- to

5-year-old children who had never visited a den-

tist. It is worrisome that only a small percentage ofthese preschool children have been to a dentist.

This finding is in accordance with others studies

performed in southern Brazilian cities; Kramer

et al. (6) showed that only 13.3% of children under

5 years of age had visited a dentist, and Ardenghi

et al. (14) showed that 24.2% of children aged 5 to

59 months had already had a first dental visit. In

Mexico, Medina-Solis et al. found that only 40% of

children had at least one dental visit in their life for

any reason. Although these levels of utilization are

Table 1. Demographic and socioeconomic variables,clinical characteristics, and maternal dental anxiety andperception of childs oral health (Pelotas, Brazil; n = 608motherchild dyads)

Variable Category

Total

n %

Sex Male 301 49.5Female 307 50.5

Age (months) 2435 175 28.83647 186 30.64860 199 32.7>60 48 7.9

Monthly family income 1.5 BMW 316 52.88 years 261 43.18 years 345 56.9

dmf-t 0 367 60.41 241 39.6

Mothers dental visits Regular 242 39.8Irregular 366 60.2

Child visited a dentist Yes 126 20.7No 482 79.3

Pain teeth/mouth Neverexperienced

430 70.7

Experienced 178 29.3Maternal dental anxiety Low 362 59.5

Moderate 110 18.1High 136 22.4

ECOHIS score 1 307 50.5>1 301 49.5

BMW, Brazilian minimum wage; ECOHIS, Early Child-hood Oral Health Impact Scale; dmft, decayed/missing/filled teeth.

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considered low, they are higher than those in thepresent study (24). Despite increasing efforts to

begin dental care very early in life, when primary

prevention of dental caries is possible, very few

children receive early care (1).

Parents bear the responsibility of taking pre-

school children to the dentist. The results of this

study showed that maternal attendance pattern is a

predictor of childrens use of dental services.

Because young childrens dental health relies on

parental involvement and support from dental ser-

vices (4), children whose mothers do not use dental

services on a regular basis can be considered atrisk. Crawford and Lennon found that, in a

deprived area, a mothers attendance was a good

predictor of childrens attendance, although a sub-

stantial proportion of mothers who did not visit

the dentist themselves did ensure the attendance of

their children (25). Previous studies have detected

an association between a childs dental visits and

parental visits to dentist for preventive reasons

and the recency of their caregivers dental visits

(26, 27). Further, Isong et al. (28) found that parents

who did not obtain dental care for themselves wereless likely to seek dental care for their children. It is

known that an individuals health decisions are

influenced by previous experience (29). Therefore,

it is likely that a mothers negative perception or

previous negative experience of dental treatment

influences not only the mothers dental care use

but also dental care use by the child.

A negative association was found between den-

tal anxiety and use of dental services in adults (12).

In a sample of preschool children, it was found that

mothers who were relaxed about their own dental

care were most likely to have preschool childrenwho were registered for dental care (27). Thomas

and Startup (30) examined the impact of a mothers

dental anxiety level on her childrens dental health:

it was not only shown to block the provision of

adequate care, but also led to dental neglect. To

our knowledge this is the first study to use a vali-

dated tool and a multivariate approach to assess

whether maternal dental anxiety is associated with

treatment avoidance in preschool children. Results

showed that, more frequently, mothers with a low

Table 2. Factors associated with a childs dental service use (Pelotas, Brazil;n = 608 motherchild dyads)

VariableVisiteda dentistn(%)

PR crude(95% CI) Pvalue

PR adjusted(95% CI) Pvalue

SexMale 67 (22.3) 1.00 Female 59 (19.2) 0.86 (0.631.18) 0.35

Age (months)2435 29 (16.6) 1.00 1.00

3647 22 (11.8) 0.71 (0.431.19) 0.20 0.75 (0.451.23) 0.234860 57 (28.6) 1.73 (1.162.57) 0.01 1.79 (1.222.63) 0.01>60 18 (37.5) 2.26 (1.383.71) 0.01 2.14 (1.30-3.54) 0.03

Family monthly income 1.5 BMW 77 (24.4) 1.00 8 years 70 (26.8) 1.00 1.00 8 years 54 (15.6) 0.58 (0.430.80) 0.01 0.65 (1.191.65) 0.01

Cavities or cariesAbsent 71 (19.4) 1.00 Present 55 (23.2) 1.21 (0.881.66) 0.23

Mother dental visitsRegular 73 (29.9) 1.00 1.00

Nonregular 53 (14.5) 0.48 (0.350.65) 0.01 0.49 (0.350.68) 0.01Pain teeth/mouth

Never experienced 71 (16.5) 1.00 1.00Experienced 55 (30.9) 1.87 (1.382.54) 0.01 1.56 (1.112.19) 0.01

Maternal dental anxietyLow 84 (23.2) 1.00 Moderate 21 (19.1) 0.82(0.541.26) 0.37 High 21 (15.4) 0.67 (0.431.03) 0.06

ECOHIS score 1 47 (15.3) 1.00 1.00>1 79 (26.3) 1.71 (1.242.37) 0.01 1.49 (1.052.13) 0.03

BMW, Brazilian minimum wage; ECOHIS, Early Childhood Oral Health Impact Scale; PR, prevalence ratio.

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level of dental anxiety had children who had

visited a dentist, but this difference was not statisti-

cally significant. The childrens own fear related to

dental care was not assessed, and this factor could

be more important than maternal anxiety of dental

visits.

The influence of demographic characteristics,

clinical variables, and socioeconomic conditionswas also assessed. Similar to other studies, an asso-

ciation was found between age and the use of den-

tal services (6, 24). However, it is important that

further studies assess whether this is associated

with the parents perception of the need for a pre-

ventive appointment or whether they took the

child because of the appearance of symptoms or

presence of oral health problems that became more

prevalent with age (6).

The utilization of dental services by children and

adolescents is often driven by the presence of pain

(31). In this sample, having experienced pain didinfluence parents taking their children to the den-

tist, whereas having teeth affected by caries did

not. However, only 30.9% of children who experi-

enced pain were taken to the dentist.

Maternal perception of their childs OHRQoL

was associated with utilization of dental services,

confirming the fact that greater oral health need

(perceived or normative) is an important predic-

tor of use of dental health services in preschool

children (24). For the youngest children, such as

those investigated in this study, a proxy ratingby caregivers is indispensable to document the

consequences of oral disorders, and it is under-

standable that poorer perception is an indicator

for parents to take their child to the dentist. This

is in agreement with observations by Sohn (26);

caregivers unfavorable perception of their chil-

drens oral health motivated them to seek dental

care for them. In contrast, a contradictory result

was found by applying a questionnaire to older

children; those who rated their oral health as

good/excellent were more likely to have visited

the dentist (10).It is known that children from low-income fami-

lies tend to have the greatest needs and lowest use

of dental services (1). Therefore, there are fewer

opportunities for dentists to intervene in cases of

these patients who are at maximum risk. It is

important to consider that, although public access

to dental treatment has spread to greater segments

of the Brazilian population, this young population

(age, 05 years) is underserved in terms of public

dental services (32).

Maternal schooling level was a determinant fac-

tor of a child having visited a dentist. This is

understandable, as the knowledge and skills

attained through education may affect a persons

cognitive functioning, making them more receptive

to health education messages or more able to com-

municate with and access appropriate health ser-

vices (33). According to Mello and Antunes, theremay be a lack of parental knowledge about the

importance of deciduous dentition (34), and some

parents might believe that the teeth of children at

this age are not important because of their tempo-

rary nature.

In many countries restorative treatment in pri-

mary teeth is suboptimal (35). In a Brazilian oral

health survey performed in 2003, 80% of 5-year-

old children presented with untreated dental

caries (36). In the present sample untreated

cavities were detected in 98.3% of the children

who presented with the disease. With regard tothe frequency of restorative dental treatment, the

high occurrence of untreated caries in this popu-

lation is alarming and could be the result of low

utilization. However, even children who visited

a dentist did not receive rehabilitation treatment.

This has also been observed by Sohn et al. (26),

who concluded that this finding could be reflec-

tive of the fact that children who received restor-

ative treatments or underwent extractions did

not receive proper therapy to prevent further

development of dental caries. It has beenreported that, when combined with preventive

care, if left unrestored the majority of carious

deciduous teeth exfoliate without the child visit-

ing his/her dentist for pain and infection (37).

Nevertheless, primary teeth of young children

are vital to their development, and every effort

should be made to retain these teeth for as long

as is possible, because there is no evidence that

no treatment is better than dental fillings for the

treatment of caries in the primary dentition (38).

The early intervention has great potential to

reduce the overall costs associated with dentaltreatment in preschool children (39). However, it is

important that further studies assess the effects of

early preventive visits on oral health outcomes and

the reasons why children do not visit a dentist by

the recommended age. Studies on the use of dental

care may help understand and predict behavior,

and consequently, help establish public health poli-

cies that encourage the use of dental care at an

early age (6). Understanding the impact of socio-

economic and psychosocial predictors of oral

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Goettems et al.


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health care use may lead to better allocation of

resources (40).

Finally, it can be concluded that there was

low utilization of dental services by preschool

children and untreated dental caries were pres-

ent even among children who had visited a den-

tist. Children of mothers with low schooling

level who do not visit a dentist regularly wereat greater risk of not receiving dental care.

Maternal perception of their childs oral health

motivated visits to the dentist.

References1. Edelstein B. Disparities in oral health and access to

care: findings of national surveys. Ambul Pediatr2002;2:1417.

2. AAPD. Policy on early childhood caries (ecc): classi-fications, consequences, and preventive strategies.

Pediatr Dent 2007;29:39

41.3. Savage MF, Lee JY, Kotch JB, Vann WF. Early pre-

ventive dental visits: effects on subsequent utiliza-tion and costs. Pediatrics 2004;114:e41823.

4. Wigen TI, Espelid I, Skaare AB, Wang NJ. Familycharacteristics and caries experience in preschoolchildren. A longitudinal study from pregnancy to5 years of age. Community Dent Oral Epidemiol2011;39:31117.

5. Eckersley AJ, Blinkhorn FA. Dental attendance anddental health behaviour in children from deprivedand non-deprived areas of salford, north-west eng-land. Int J Paediatr Dent 2001;11:1039.

6. Kramer PF, Ardenghi TM, Ferreira S, Fischer Lde A,

Cardoso L, Feldens CA. [Use of dental services bypreschool children in Canela, Rio grande do sul state,Brazil]. Cad Saude Publica 2008;24:1506.

7. Barros AJD, Bertoldi AD. Desigualdades na uti-lizacao e no acesso a servicos odontologicos: uma av-aliacao em nvel nacional. Ciencia e saude coletiva2002;7:70917.

8. Brickhouse TH, Unkel JH, Kancitis I, Best AM, DavisRD. Infant oral health care: a survey of general den-tists, pediatric dentists, and pediatricians in virginia.Pediatr Dent 2008;30:14753.

9. Ismail AI, Nainar SM, Sohn W. Childrens first dentalvisit: attitudes and practices of us pediatricans andfamily physicians. Pediatr Dent 2003;25:42530.

10. Piovesan C, Antunes JL, Guedes RS, Ardenghi TM.Influence of self-perceived oral health and socioeco-nomic predictors on the utilization of dental care ser-vices by schoolchildren. Braz Oral Res 2011;25:1439.

11. Barros AJD, Bertoldi AD. Desigualdades na uti-lizacao e no acesso a servicos odontologicos: uma av-aliacao em nvel nacional. Ciencia e saude coletiva2002;7:70917.

12. Eitner S, Wichmann M, Paulsen A, Holst S. Dentalanxietyan epidemiological study on its clinical cor-relation and effects on oral health. J Oral Rehabil2006;33:58893.

13. IBGE. Estimativas de Populacao. 2006 Available at:http://www.ibge.gov.br/home/estatistica/populacao/

estimativa2009/POP2009_DOU.pdf [last accessed 14August 2009].

14. Ardenghi TM, Ferreira FV, Piovesan C, MendesFM. Age of first dental visit and predictors fororal healthcare utilization in preschool children.Oral Health Prev Dent 2012; [Epub ahead ofprint].

15. Goettems ML, Ardenghi TM, Romano AR, DemarcoFF, Torriani DD. Influence of maternal dental anxiety

on oral health-related quality of life of preschool chil-dren. Qual Life Res 2011;20:9519.16. Camargo MB, Dumith SC, Barros AJ. [Regular use of

dental care services by adults: patterns of utilizationand types of services]. Cad Saude Publica 2009;25:1894906.

17. Hu LW, Gorenstein C, Fuentes D. Portuguese ver-sion of corahs dental anxiety scale: transculturaladaptation and reliability analysis. Depress Anxiety2007;24:46771.

18. Corah NL, Gale EN, Illig SJ. Assessment of a dentalanxiety scale. J Am Dent Assoc 1978;97:81619.

19. Tesch FC, de Oliveira BH, Leao A. Semantic equiva-lence of the brazilian version of the early childhood

oral health impact scale. Cad Saude Publica2008;24:1897909.20. Pahel BT, Rozier RG, Slade GD. Parental perceptions

of childrens oral health: the early childhood oralhealth impact scale (ECOHIS). Health Qual Life Out-comes 2007;5:6.

21. Peres MA, Traebert J, Marcenes W. Calibracao de ex-aminadores para estudos epidemiologicos de cariedentaria. Cad Saude Publica 2001;17:1539.

22. WHO. Oral health survey basics methods, 4th edn.Geneva: World Health Organization; 1997.

23. Drury TF, Horowitz AM, Ismail AI, Maertens MP,Rozier RG, Selwitz RH. Diagnosing and reportingearly childhood caries for research purposes. Areport of a workshop sponsored by the national insti-tute of dental and craniofacial research, the healthresources and services administration, and thehealth care financing administration. J Public HealthDent 1999;59:1927.

24. Medina-Sols CE, MaupomeG, Avila-Burgos L, Hi-jar-Medina M, Segovia-Villanueva A, Perez-NunezR. Factors influencing the use of dental health ser-vices by preschool children in mexico. Pediatr Dent2006;28:28592.

25. Crawford AN, Lennon MA. Dental attendance pat-terns among mothers and their children in an area ofsocial deprivation. Community Dent Health1992;9:28994.

26. Sohn W, Ismail A, Amaya A, Lepkowski J. Determi-

nants of dental care visits among low-income afri-can-american children. J Am Dent Assoc 2007;138:30918. quiz 95-96, 98.

27. Kinirons M, McCabe M. Familial and maternal fac-tors affecting the dental health and dental attendanceof preschool children. Community Dent Health1995;12:2269.

28. Isong IA, Zuckerman KE, Rao SR, Kuhlthau KA, Wi-nickoff JP, Perrin JM. Association between parentsand childrens use of oral health services. Pediatrics2010;125:5028.

29. Rosenstock IM. Why people use health services. Mil-bank Q 2005;83:132.

457



8/9

30. Thomas JF, Startup R. Some social correlates withthe dental health of young children. CommunityDent Health 1992;9:1117.

31. Villalobos-Rodelo JJ, Medina-Sols CE, Maupome G,Lamadrid-Figueroa H, Casanova-Rosado AJ, Casa-nova-Rosado JF et al. Dental needs and socioeco-nomic status associated with utilization of dentalservices in the presence of dental pain: a case-controlstudy in children. J Orofac Pain 2010;24:27986.

32. Pucca GA, Costa JF, Chagas LED, Sivestre RM. Oralhealth policies in brazil. Braz Oral Res 2009;23(Suppl1):916.

33. Galobardes B, Shaw M, Lawlor DA, Lynch JW, DaveySmith G. Indicators of socioeconomic position (part1). J Epidemiol Community Health 2006;60:712.

34. Mello TR, Antunes JL. [Prevalence of dental caries inschoolchildren in the rural area of Itapetininga, SaoPaulo state, Brazil]. Cad Saude Publica 2004;20:82935.

35. Splieth CH, Bunger B, Pine C. Barriers for dentaltreatment of primary teeth in east and west germany.Int J Paediatr Dent 2009;19:8490.

36. Ministerio da Saude. Projeto SB brasil 2003. Condi-coes de saude bucal da populacao brasileira, 20022003: Resultados principais. Braslia: Ministerio daSaude; 2004: 52.

37. Levine RS. How should we manage caries in decidu-ous teeth? Dent Update 2008;35:4068.

38. Yengopal V, Harneker SY, Patel N, Siegfried N. Den-tal fillings for the treatment of caries in the primarydentition. Cochrane Database Syst Rev 2009;15;(2):

CD004483.39. Lee JY, Bouwens TJ, Savage MF, Vann WF. Examin-ing the cost-effectiveness of early dental visits. Pedi-atr Dent 2006;28:1025. discussion 92-8.

40. Medina-Solis CE, Maupome G, del Socorro HM,Perez-Nunez R, Avila-Burgos L, Lamadrid-FigueroaH. Dental health services utilization and associatedfactors in children 6 to 12 years old in a low-incomecountry. J Public Health Dent 2008;68:3945.

458

Goettems et al.


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