ISSN 0970-4388

JISPPD
Journal of Indian Society of Pedodontics and Preventive Dentistry

Journal of Indian Society of

Pedodontics and Preventive Dentistry
April-June 2010 / Vol 28 / Issue 2
•

Online full text at www.jisppd.com

Volume 28
•
Issue 2
•
April - June 2010
•
Pages 59-139

S O C I E TY
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Official Publication of
The Indian Society of Pedodontics and Preventive Dentistry
ORIGINAL ARTICLE
Knowledge, attitude and practice of oral
health promoting factors among caretakers of
children attending day-care centers in Kubang
Kerian, Malaysia: A preliminary study
Abstract
Background and Aim: The role of caretakers at day-care
centers has become more imperative in promoting oral health
care in children since many new mothers opt to work outside
their homes, leaving their children at day-care centers. The
aim of this study is to assess the knowledge, attitude and
practice of oral health promoting factors among secondary
caretakers of children attending day-care centers. Settings
and Design: This was a cross-sectional exploratory study
conducted among secondary caretakers in Kubang Kerian,
Malaysia. Materials and Methods: Thirty-four caretakers
fulfilling the inclusion and exclusion criteria participated in
the study. The data were collected using a self-administered
questionnaire addressing various aspects of knowledge,
attitude and practice of oral health in children. Analysis was
done using SPSS version 12.0. Results: The knowledge of
factors causing dental caries was found to be good among
majority of the caretakers, but the concepts of transmissibility
of caries and effect of hidden sugars were not evident. Seventy
one percent did not know that frequent bottle feeding could
cause tooth decay. Attitudes seemed to be governed by the
cultural practices of the region rather than the knowledge
obtained. The knowledge was not translated to practice
adequately. Giving sweetened liquid in bottles was practiced
by 53% of the caretakers. Conclusion: Implementation of
nursery-based oral health promotion programs for secondary
caretakers is needed to counteract early childhood caries.
Key words
Attitude, caretakers, early childhood caries, infant oral health,
knowledge, oral health promotion, practice
DOI: 10.4103/0970-4388.66741 PMID: ****
78 J INDIAN SOC PEDOD PREVENT DENT | Apr - June 2010 | Issue 2 | Vol 28 |
Mani SA, Aziz AA, John J1, Ismail NM
School of Dental Science, Universiti Sains Malaysia, 16150
Kota Bharu, Kelantan, Malaysia.
1
Department of General Dental Practice and Oral and
Maxillofacial Imaging, Faculty of Dentistry, Universiti Malaya,
50603 Kuala Lumpur, Malaysia.
Correspondence:
Dr. Shani Ann Mani, School of Dental Science, Universiti
Sains Malaysia, 16150 Kubang Kerian, Kota Bharu, Kelantan,
Malaysia. E-mail: shani_jacob@yahoo.co.in
Introduction
Oral health is an important aspect of general health in
infants and children and impacts the quality of life and
health outcomes.[1] Although dental caries’ levels have
declined and stabilized the world over, the problem of
early childhood caries (ECC) has remained persistent in
many areas of the world affecting certain segments of
society, especially the socially deprived,[2,3] who remain
at high-risk to this disease. The factors associated
with ECC include low income families,[4-7] cultural
differences,[2,8,9] child temperament,[10] fewer dental
visits,[11,12] lower educational level of the mother,[13,14]
low levels of oral health knowledge among mothers,[15]
inadequate oral hygiene[6,16,17] and a highly cariogenic
diet in these children.[6,17-21]
Majority of the studies have focused on parent/
primary caretaker’s attitudes and beliefs which put
the child at risk for ECC.[15,22-26] Fewer studies have
been done to determine schoolteacher’s oral health
knowledge and his/her behavior toward children.[27-30]
Most studies concerning ECC do not cater to the
 Mani, et al.: KAP among caretakers in Kubang Kerian, Malaysia

culture, environment and individual-level factors within
a system with its own societal and environmental
characteristics.[31] More attention needs to be focused
on family dynamics and behavior in solving the problem
of ECC.[32]
Mothers are undoubtedly the primary source of early
education in children with regard to a good oral health.
However, in the 21st century, the numbers of mothers
employed outside their homes continue to rise, perhaps
in an attempt to increase the quality of life. As a result,
young children spend a considerable amount of time
in day-care centers. In day-care centers, the caretakers’
role is similar to that of school teachers and may be
even more important because they are involved in
children's daily diet, general hygiene and oral health
care. Despite this, no study to the best of our knowledge
has focused on determining the role of such caretakers
in promoting oral health among children.
This pilot study was undertaken to assess the
knowledge, attitude and practice of oral health
promoting factors in infants and young children among
caretakers at day-care centers.
Materials and Methods
This cross-sectional study involved caretakers working
in all the day-care centers in Kubang Kerian, Malaysia.
From a total of 11 day-care centers employing 40
individuals, 34 consented to participate in the study.
Consent was obtained from the proprietor of each
nursery after explaining the nature of research. All
the caretakers who fulfilled the inclusion criteria were
approached. Inclusion criteria for the caretakers were
(1) they should be aged 18 years or above, (2) those who
took care of normal/healthy children and (3) those who
were employed as caretakers for more than 3 months.
Since all the subjects fulfilled the inclusion criteria, none
were excluded. Informed consent was then obtained
dentist and community dental health specialist. It
had 29 items, 10 each in the knowledge and practice
components and 9 in the attitude component, and took
about 20 minutes to complete. The scoring for attitude
and practice was based on 5- and 4- point Likert scale,
respectively, while the scoring for knowledge included
true/false/don’t know responses. All aspects of oral
health promoting factors in children including oral
hygiene, diet and fluoride were addressed.
Data were entered and analyzed using SPSS 12.01.[33]
The ethical clearance was obtained from the Human
Ethics Committee of Universiti Sains Malaysia.
Results
The demographic characteristics of the caretakers are
shown in Table 1. Children under their care were aged
between 1 and 5 years. Each caretaker was responsible
for 2 to 19 children, depending on the day-care center.
The mean duration of their services was 9.9 h/day,
which was determined by the parents’ working hours.
Most of the caretakers had secondary school education,
with only three individuals having any form of tertiary
education. A majority (52.9%) had more than 1 year of
experience as a caretaker, but a quarter had less than
1 year experience.
Table 2 shows the knowledge of the caretakers. Most
of them had good knowledge of a child’s tooth eruption
stages, role of fluoride and tooth brushing in caries
development. About 32% knew that caries can affect
Table 1: Sociodemographic characteristics of the respondents
Variables n (%)
Age Mean: 30.5 years
Gender Female 34 (100)
Ethnic Group Malay 34 (100)
Education level Primary 2 (5.9)
Secondary 29 (85.3)
Tertiary 3 (8.8)

from every caretaker who participated in the study. Daily working time (hours) Mean: 9.9 hours
Duration of employment 3 months to 1year 9 (26.5)
The caretakers were required to answer a close-ended Between 1 and 5 years 18 (52.9)
self-administered questionnaire. Sociodemographic More than 5 years 7 (20.6)
details taken from the caretakers included (1) daily Primary job option Yes 22 (65)
working hours as caretakers, (2) employment duration No 12 (35)
and (3) whether this occupation was their first choice. Number of children under care 1–5 12 (35)
The questionnaire addressed the knowledge, attitude 6–10 9 (26.5)
and practice of oral health promoting factors among
11–15 9 (26.5)
infants and young children, designed jointly by the
16–20 4 (11.8)
research group with the expert opinion of a pediatric

J INDIAN SOC PEDOD PREVENT DENT | Apr - June 2010 | Issue 2 | Vol 28 | 79
 Mani, et al.: KAP among caretakers in Kubang Kerian, Malaysia

Table 2: Knowledge of infant oral health among the Table 3: Attitudes of the respondents to infant oral health
respondents
Items Strongly Don’t Strongly
Items True (T) False (F) Don’t know agree/agree know disagree/
n (%) n (%) n (%) n (%) n (%) disagree n (%)
Caries can affect infants below 2 11 (32.4) 22 (64.7) 1 (2.9) Tooth decay is caused by bacteria 5 (14.7) 3 (8.8) 26 (76.4)
years old that are transmitted by sharing
When does the first baby tooth 31 (91.2) 3 (8.8) 0 (0.0) feeding utensils (e.g: spoon)
appear in the child’s mouth? A balance diet is essential for the 31 (91.2) 3 (8.8) 0 (0.0)
Complete set of 20 baby teeth by 24 (70.6) 8 (23.5) 2 (5.9) healthy growth of a baby’s teeth
the age Night time bottle/breast feeding can 10 (29.4) 5 (14.7) 19 (55.9)
The main types of food that can 33 (97.1) 0 (0.0) 1 (2.9) cause tooth decay
cause tooth decay ... Frequent and prolonged breast/bottle 9 (26.5) 1 (2.9) 24 (70.6)
feeding can cause tooth decay
Weaning from a baby bottle to 31 (91.2) 2 (5.9) 1 (2.9)
a sipping cup should be planned A child’s teeth should be cleaned/ 32 (94.1) 1 (2.9) 1 (2.9)
when the child is: brushed
Cleaning a baby’s mouth after each 31 (91.2) 2 (5.9) 1 (2.9) Effective cleaning of teeth brushing 19 (55.9) 2 (5.9) 13 (38.2)
feeding should begin even before can be achieved by the child him/
teeth erupt herself
Brushing baby’s teeth is important 33 (97.1) 0 (0.0) 1 (2.9) Swallowing of toothpaste can be 6 (17.6) 3 (8.8) 25 (73.5)
for oral health harmful to a child’s health
Fluoride in toothpaste is important 31 (91.2) 1 (2.9) 2 (5.9) It is important for a child to visit the 13 (38.2) 1 (2.9) 20 (58.8)
for preventing caries in teeth dentist before 2 years old
You should start using toothpaste 13 (38.2) 19 (55.9) 2 (5.9) Prolonged used of pacifier can affect 22 (64.7) 4 (11.8) 8 (23.5)
with fluoride for cleaning a child’s the normal development of a child’s
teeth… teeth
It is not necessary to do fillings in 21 (61.8) 8 (23.5) 5 (14.7)
baby’s teeth Worldwide, the numbers of mothers working outside
their homes continue to increase; 70–80% in Poland[18]
infants below 2 years old and about 38% of caretakers and 45–55% in Malaysia. These women have to balance
knew the right time for using fluoride toothpaste for the responsibilities of the family and workplace.
tooth cleaning. Only 24% knew that fillings in baby Working parents of children in nuclear families have
teeth were necessary. mainly two options, to leave the child at home with a
family member/hired help or to leave the child at a
Table 3 shows the caretaker’s attitude toward infant nursery or day-care center, which caters to children
oral health. Five respondents agreed that tooth decay as young as 3 months. Parents opt to leave children
is caused by bacteria transmitted by sharing utensils, at such centers for the majority of the day, during
while 56 and 71% thought that nighttime and frequent the working hours of the parent. Most nurseries are
bottle feeding/breast feeding did not cause tooth small, private organizations, located at residential
decay, respectively. About 18% strongly agreed that areas, which may or may not be registered with the
swallowing of toothpaste can be harmful to a child’s local department of community welfare. Hence, these
health. organizations may not have the ideal requirements and
reach the standards of an ideal nursery. The parents
Table 4 shows the responses to oral health practices. have limited control of activities in the nursery, and
About 17.6% of the caretakers agreed to having bitten there may be inadequate knowledge and standardization
food into small pieces before giving it to the children. of procedures regarding child caring among caretakers
About 85% acknowledged giving sweet food to the child in such centers.
and 53% to giving sweetened liquid in bottle.
The caretakers in this study were all Malay females,
Discussion which reflect the ethnic group comprising the majority
in the state of Kelantan, Malaysia. Thirty five percent
Knowledgeable and efficacious caregivers can play did not opt for infant caretaking as their first job
an important role in caries prevention.[4] Child care option, which suggests that a lack of preferred job
centres serve a significant number of young children opportunities may have prompted them to take up
and deserve attention as potential venues for early this profession temporarily which in turn can result in
preventive and corrective oral interventions.[9] decreased quality of care.

80 J INDIAN SOC PEDOD PREVENT DENT | Apr - June 2010 | Issue 2 | Vol 28 |
 Mani, et al.: KAP among caretakers in Kubang Kerian, Malaysia

Table 4: The respondents’ practices of infant oral health care

Items Always (A) Frequent (F) Sometimes (S) Never (N)
n (%) n (%) n (%) n (%)
Do you bite the food into small pieces before giving to the children at the nursery? 1 (2.9) 2 (5.9) 3 (8.8) 28 (82.4)
How often did you do mouth examination on children in nursery 3 (8.8) 5 (14.7) 19 (55.9) 7 (20.6)
How often did you give sweet food to the children? 0 (0.0) 0 (0.0) 29 (85.3) 5 (14.7)
How often did you give sweetened liquid/juice to the baby in bottle? 1 (2.9) 1 (2.9) 18 (52.9) 14 (41.2)
How often did you give plain water after each feed? 14 (41.2) 14 (41.2) 5 (14.7) 1 (2.9)
When do you start semisolid food for a child at the nursery? 1 (2.9) 22 (64.7) 10 (29.5) 1 (2.9)
□ 6 months (A)
□ 1 year (F)
□ 1½ years (S)
□ 2 years (N)
How often do you clean a child’s teeth at the nursery? 9 (26.5) 7 (20.6) 11 (32.4) 7 (20.6)
How much toothpaste do you use to brush a child`s teeth? 15 (44.1) 10 (29.4) 0 (0.0) 9 (26.5)
□ Smear (A)
□ Pea size (F)
□ Full brush length (S)
□ Not at all (N)
Do you use pacifier dipped into sweet liquid for a child? 1 (2.9) 2 (5.9) 1 (2.9) 30 (88.2)
Do you take the effort to improve your dental health knowledge? 12 (35.3) 7 (20.6) 5 (14.7) 10 (29.4)

Only 42 and 39% of mothers knew that dental caries
is caused by sugar in Wuhan, Republic of China, and
Romania, respectively, and relatively few mothers
knew the effect of sugary drinks like tea, coffee and
milk.[27,28] Elsewhere, 78% knew that sugary foods
and drinks should be limited to meal-times, but only
7% could select the four foods and drinks that supply
children with the bulk of their added sugar intake.[34]
In this study, most of the caretakers (97%) knew that
sugary food can cause tooth decay, but on the contrary,
majority (59%) indulged in giving sweetened liquid in
the bottle and 85.3% gave sweet food to the children.
Seventy one percent and 56% of them also disagreed
that dental caries is caused by frequent/prolonged
feeding and nighttime feeding, respectively. This might
be because they were not aware of the hidden sugars in
the milk, or that giving the children bottle or breast feed
immediately prior to bedtime and when the child woke
up in the night was a common cultural practice of the
region. Additionally, weaning from the bottle was also
done quite late; only 3% of the caretakers practiced the
right time to start giving semisolid food for a child at
the nursery and most of them (64.7%) started feeding
semisolid food for a child at the nursery at the age of 1
year, thus increasing the risk factors for caries.
The foundation of adult oral health is laid during
the formative preschool years, during which a child’s
dental caries pattern and caries risk are established.[35]
Good oral hygiene in the early years of life is associated
with decreased caries experience in the individual in
later life.[36,37] Time constraints in the schedule of
parents working outside the home may put children at
a disadvantage in learning satisfactory oral habits at
home, whereas secondary caretakers can play a major
role in inculcating good oral habits in these children.
A study in Poland reported that 54% of mothers
regularly assist their child with tooth brushing
and the proportion is greatest among mothers with
higher education.[15] On the other hand, statistically
significant difference between decayed, missing and
filled teeth (dmft) index and self brushing, parental
brushing or tooth brushing with parental assistance,
was not found in another study. [18] In this study,
91.2% of the caretakers knew that cleaning a baby’s
mouth after each feeding should begin even before the
teeth erupt and 97.1% were aware that brushing is
important for oral health. Half of the subjects in this
study agreed that effective cleaning of teeth cannot
be achieved by the child him/herself, yet 53% of the
caretakers ‘seldom’ or ‘never’ brushed the teeth of the
children or assisted them. An excellent way to instill
oral hygiene habits in these children is to conduct a
regular exercise of tooth brushing everyday in the
day-care center with the assistance of the caretakers.
Basic habits like drinking plain water and rinsing the

J INDIAN SOC PEDOD PREVENT DENT | Apr - June 2010 | Issue 2 | Vol 28 | 81
 Mani, et al.: KAP among caretakers in Kubang Kerian, Malaysia
mouth with water after every feed can also be instilled
in children at a young age. In this study, only 42%
reported encouraging drinking plain water after every
feed at all times.
About 62% of the caretakers in this study agreed that
it was not necessary to do fillings in deciduous teeth,
with similar results reported from a study in Poland
where two-thirds of the mothers agreed that care of
deciduous dentition was unnecessary.[15] In contrast,
a study in England concluded that 74% of mothers
thought that dental decay in milk teeth was very
important, but only about 47% wanted carious teeth
filled, while 15% wanted them to be left and 28% wanted
them extracted.[34] In a multicultural community
in USA, half the participants believed that children
should see a dentist between 2 and 4 years of age.[31] A
majority (79.4%) in this study did mouth examination
in the children but 58.8% did not believe that children
should see a dentist before 2 years of age. For this
reason, caretakers should be trained to identify carious
deciduous teeth and highlight to parents the importance
of its preservation and visiting a dentist at the earliest.
The role of bacteria in the etiology of caries was
acknowledged by 33 and 35% of Romanian and Chinese
mothers, respectively.[27,28] In this study, only 15%
agreed that tooth decay was caused by bacteria that
were transmitted by sharing feeding utensils (e.g.,
spoon). Moreover, about 18% caretakers reported biting
the food into small pieces before giving it to the children
at the nursery. Hence, this implicates that oral health
education should address concepts of transmissibility
of oral bacteria.
Despite having good levels of knowledge of the causes
of dental caries, the caretakers appeared to be unable to
apply the knowledge in everyday practice. Good levels
of knowledge is probably due to the wide exposure to
oral health education and promotion among Malaysians
through school dental service, antenatal clinics and
other avenues, carried out by the Ministry of Health.
The school dental service in Malaysia provides oral
health promotion, preventive and curative activities
using the school dental clinic, mobile dental chair
and mobile teams, with the aim of rendering school
children orally fit before they leave school. The poor
practices may be due to the cultural practices observed
in the region, which remains unchanged in spite of the
knowledge obtained, which was also noted by Matilla et
al.[18] A similar finding was noted in Serdang, Malaysia,
where the knowledge and attitude of parents toward
82 J INDIAN SOC PEDOD PREVENT DENT | Apr - June 2010 | Issue 2 | Vol 28 |
oral health was not reflected in the oral health of their
children.[38]
This being a pilot study, conducted in one locality,
conclusions cannot be applied to the population, thus
requiring studies with larger samples. However, the
preliminary findings indicate that the attitudes and
practices of caretakers need improvement and the
community would benefit if the caretakers undergo
frequent compulsory standardized training pertaining
to child rearing, which includes oral health promoting
factors. The administrators of day-care centers
should support and encourage such training among
caretakers to enhance the quality of care. It would also
be interesting to compare the caries status of children
placed in such day-care centers with those under the
care of mothers, to find out if placing children in day-
care is a risk factor for ECC.
In conclusion, most caretakers had good knowledge, but
the same did not reflect in their attitude and practice. It
is worthwhile to attempt regular oral health promotion
education programs, with stress on dietary practices
and other preventive measures among caretakers of
child care centers.
Acknowledgement
Participants of the study and Dr. Lin Naing are thanked for
their help and support.
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Source of Support: Nil, Conflict of Interest: Nil
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