Dental caries and externalizing behaviour problems in a high-risk child population - TNO Publications
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Eur J Oral Sci 2018; 1–9 © 2018 The Authors. Eur J Oral Sci published by John Wiley & Sons Ltd
DOI: 10.1111/eos.12542 European Journal of
Printed in Singapore. All rights reserved
Oral Sciences
Maddelon de Jong-Lenters1,2,
Dental caries and externalizing Denise Duijster3 , Annemarie
Schuller1,4, Cor van Loveren2,5,
behaviour problems in a high-risk Erik Verrips1,5
1
TNO, Netherlands Organisation for Applied
child population Scientific Research, Leiden; 2Department of
Cariology Endodontology Pedodontology,
Academic Centre for Dentistry Amsterdam,
University of Amsterdam and VU University,
Amsterdam; 3Department of Social Dentistry,
de Jong-Lenters M, Duijster D, Schuller A, van Loveren C, Verrips E. Dental caries Academic Centre for Dentistry Amsterdam,
and externalizing behaviour problems in a high-risk child population. University of Amsterdam and VU University,
Amsterdam; 4Centre for Dentistry and Oral
Eur J Oral Sci 2018; 00: 1–9. © 2018 The Authors. Eur J Oral Sci published by John
Hygiene (CTM), University Medical Center
Wiley & Sons Ltd. Groningen, Groningen; 5Department of
Preventive Dentistry, Academic Centre for
The aim of this study was to assess the association between externalizing behaviour Dentistry Amsterdam, University of
problems and dental caries in children. A further objective was to explore direct Amsterdam and VU University, Amsterdam,
and indirect pathways between sociodemographic factors, family functioning and the Netherlands
parenting factors, oral health behaviours, externalizing behaviour problems, and
dental caries using structural equation modelling. Cross-sectional data were col-
lected on 251, 5- to 8-yr-old children from a paediatric dental practice in the
Netherlands. Children’s decayed, missing, and filled primary teeth (dmft) scores Maddelon de Jong-Lenters, ACTA,
Department of Cariology Endodontology
were obtained from their dental records. Validated self-report questionnaires were Pedodontology, Academic Centre for
used to collect sociodemographic, behavioural, and family-related data. Externaliz- Dentistry Amsterdam, University of
ing problem behaviour was significantly associated with a higher dmft score [inci- Amsterdam and VU University, Gustav
dence risk ratio (IRR) = 1.19; 95% CI: 1.06–1.34], but this association did not Mahlerlaan 3004, 1081 LA Amsterdam,
remain significant after adjustment for sociodemographic factors (IRR = 1.11; 95% the Netherlands
CI: 0.99–1.26). A valid path model was presented after applying some modifications. E-mail: m.lenters@acta.nl
Findings from the model suggest that it is plausible that child behaviour problems
are directly associated with dental caries via toothbrushing behaviour. The model
Key words: dental caries; oral health;
also provided support that maternal education level, the restrictiveness and warmth parenting; problem behaviour
of parenting, and the communication of the family, play an indirect role in the asso-
ciation between children’s externalizing behavioural problems and dental caries This is an open access article under the
terms of the Creative Commons Attribution
experience. License, which permits use, distribution and
reproduction in any medium, provided the
original work is properly cited.
Accepted for publication May 2018
Externalizing behaviour problems have been increas- influential factor on both children’s problem behaviour
ingly diagnosed in children in developed countries (1, and the adoption of children’s health behaviours (9).
2). Examples of externalizing behaviour problems are Family interactions, such as expression of affection,
attention-deficit hyperactivity disorder (ADHD), tem- parents’ discipline practices, and family routines, pro-
perament, impulsiveness, and general conduct problems vide the context in which parents’ behavioural direc-
(3). There is evidence to suggest that externalizing child tions are delivered to and interpreted by the child.
behaviour problems and dental caries are related. WIL- There are several aspects of the family environment
LIAMSON et al. found that externalizing behaviour prob- (i.e. parenting and family functioning) that have been
lems were significantly more prevalent in caries-active associated with negative child outcomes, such as an
children than in caries-free children (4). Greater dental unhealthy diet, dental caries, and behaviour problems
caries experience has been reported in children with in children (10–12). Parenting has been described as a
ADHD (5, 6), yet other studies have claimed that the versatile and complex behavioural pattern consisting of
levels of caries are actually lower in this group of two dichotomies: warmth vs. hostility; and restrictive-
children (7, 8). ness vs. autonomy (13). Family functioning is a broader
There are several plausible explanations for the rela- concept that describes how the interactions between all
tionship being positive. A possible direct explanation is family members affect the way in which both children
that good oral hygiene and limiting the intake of sug- and parents manage daily life (14). Greater dental car-
ary snacks is more challenging in children with exter- ies experience was found in children of families with
nalizing problem behaviour (7) because such children ineffective parenting, characterized by high levels of
potentially show lower levels of compliance. Indirectly, demand, along with low levels of positive involvement
the family environment could be an underlying and encouragement (15, 16), and in children of poor2 de Jong-Lenters et al.
functioning families in terms of inadequate communica- dental caries was based on clinical examinations supported
tion, low levels of responsiveness, and poor organiza- by dental radiographs, mostly bitewings, on the condition
tion (17, 18). Similar aspects of parenting and family that the patient cooperated. The dental examinations and
functioning have also been associated with an increased interpretation of dental radiographs were performed by
risk of externalizing behaviour problems, in addition to two paediatric dentists working at the centre. They used
protocolled procedures for recording diagnosed dental car-
aspects such as high levels of conflict and harsh disci- ies lesions and reasons for restorations or extractions in the
pline practices (12, 14). It has not yet been investigated electronic patient record, every time that patients attended
whether certain aspects of the family environment are the centre. Children’s dmft scores [i.e. the sum of decayed
common determinants for the development of both (d), missing (m), and filled (f) deciduous teeth] were
dental caries and externalizing behaviour problems in obtained from these dental health records, using data of
children. the children’s most recent visit to the paediatric dental cen-
In summary, the literature on the relationship between tre. Missing teeth were not scored if they were absent as a
child externalizing behaviour problems and dental caries result of dental trauma, hypomineralization, agenesis, or
is contradictory, and therefore inconclusive. In addition, normal exfoliation; they were only scored if records indi-
the underlying mechanisms of this potential relationship cated that they were extracted because of caries.
Externalizing behaviour problems in children were
remain unclear. Therefore, the primary aim of this study
scored by combining the ‘hyperactivity-inattention’ and
was to assess the association between externalizing beha- ‘conduct problems’ domains of the Strengths and Difficul-
viour problems and dental caries in children. A further ties Questionnaire (SDQ) (19). This is a concise question-
objective was to explore direct and indirect pathways naire that has proven of value, over time, to measure
between sociodemographic factors, family functioning psychosocial adjustment in children and adolescents. The
and parenting factors, oral health behaviours, externaliz- parental version for children aged 4–17 yr was used in this
ing behaviour problems, and dental caries in children study. Both subscales consist of five items with answers on
using structural equation modelling. a three-point Likert scale (0 being ‘not true’, 1 being
‘somewhat true’, and 2 being ‘certainly true’). An example
of an item used to measure ‘conduct problems’ is ‘My
child often lies or cheats’; an example of an item measur-
Material and methods ing ‘hyperactivity-inattention’ scale is ‘My child is easily
distracted, concentration wanders’. The SDQ scores for
Approval for this study was obtained from the Ethics
both subscales were categorized into average, elevated,
Committee for patient-related research of the VU Univer-
and high using normative cut-off points from the original
sity (VU METC, nr 2012/393). All parents signed written
Dutch SDQ (20). Given the low number of children allo-
consent forms before their children were included in the
cated to the high and elevated categories, these were com-
study.
bined into one category: elevated/high. Subsequently,
children were grouped as having externalizing behaviour
Study sample problems if they had elevated or high scores for hyperac-
tivity-inattention and/or conduct problems.
The data for this study were collected in a referral centre for A parental-administered questionnaire was used to col-
paediatric dental care in Noordwijk (the Netherlands), to lect information about sociodemographic variables, such
which children are referred for various diagnoses, including as the child’s date of birth, gender, the mother’s country
early childhood caries in very young children, congenital of birth, and the mother’s highest completed level of edu-
dental disorders, psychological problems, behaviour man- cation. The mother’s country of birth was categorized into
agement problems, dental fear, and developmental prob- the Netherlands or any other country. There were three
lems. A small percentage of the children have special needs categories of educational level: (i) lower education (no
associated with physical or learning difficulties. The ages of education, elementary school, and lower general educa-
children referred to the centre vary widely. For the purposes tion); (ii) intermediate education (higher general education
of this study, all children between 5 and 8 yr of age were and lower vocational education); and (iii) higher education
selected from the referral centre’s patient population. Chil- (higher vocational education or university). Oral health
dren with special needs were excluded. Because the aim of behaviours were measured using two items: the age at
the study was exploratory, no a priori hypotheses were put which toothbrushing was started (Dental caries and behaviour problems 3
one item used to measure organization is ‘We strive for the two subscales of the CRPR were classified as low or
order and regularity in our household’. All nine answers high on the basis of the median of the two scale scores in
in each subscale were summed, resulting in subscale scores the current study. If there were one or two missing items
ranging from 9 to 45. Higher scores indicate poorer func- in one subscale, the mean subscale score was imputed.
tioning. Each subscale is subsequently classified into nor- This was the case in 1.6% of the responses for the parent-
mal, subclinical, and clinical family functioning using ing subscales. Table 1 presents an overview of the family
normative cut-off scores provided by the authors of the domains measured in this study, including a definition of
instrument (14). When a value for one item was missing, each domain, the number of items per subscale, and inter-
the mean score for the remaining eight items of that sub- nal consistency.
scale was calculated and added to the total score of that
subscale. This was the case in 4.4% of the responses for
the subscale responsiveness and in 4.8% of the responses Statistical analysis
for the subscale organization. STATA version 15 (Stata, College Station, TX, USA) was
The Child Rearing Practices Report (CRPR) was used used for statistical analysis. In all hypothesis-testing, a test
to assess the norms, values, attitudes, behaviours, and result for which a value of P < 0.05 was obtained was con-
intent of either maternal or paternal parenting. This sidered to indicate a statistically significant deviation from
instrument has proven reliability and construct validity the null hypothesis. As the dmft was a non-normally dis-
over time (21). Of the 40 items in total, 22 measure the tributed count variable, Poisson regression was used to
restrictiveness of parents (for example: ‘I do not accept my assess the association between externalizing behaviour
child getting angry at me’). The other 18 items assess nur- problems and dmft. The association was subsequently
turance (example being ‘I think you should comfort a adjusted for age, gender, and the mother’s education level
child when it is upset’). As no normative scores have been and country of birth, to correct for potential confounders.
published for the CRPR, the total scores obtained with Univariate analyses were performed to assess whether
sociodemographic variables, oral health behaviours, family
functioning, and parenting variables were associated with
dmft (Poisson regression) and with externalizing behaviour
Table 1
problems (logistic regression).
Definition, number of items, and internal consistency for social– Structural equation modelling was used to test the fit of
behavioural constructs an a priori hypothesized path model of direct and indirect
pathways between sociodemographic variables, family
No. of Cronbach’s functioning and parenting variables, oral health beha-
Constructs Definition items a viours, child behaviour problems, and dmft. The hypothe-
sized path model is shown in Fig. 1, including the a priori
Family functioning (GVL)
Responsiveness To what extent 9 0.75
hypotheses. All variables in the path model were included
parents respond to as categorical variables, except for the count variable
the needs of their dmft. Unstandardized and standardized path coefficients
child in different were reported. The following goodness-of-fit measures
personal and were assessed to determine the adequacy of model fit to
cognitive fields. the data: the v2/d.f. ratio and its P-value, the root mean
Communication Parent–child 9 0.76 square error of approximation (RMSEA), the standardized
interaction: the root mean square residual (SRMR), and the comparative
degree they listen fit index (CFI). Good fit was indicated by a nonsignificant
to each other and v2 value, RMSEA and SRMR values below 0.07, and a
respond to each CFI value greater than 0.95. In the event of poor fit, mod-
other’s needs in ifications to the model were explored to improve model fit,
harmonious and based on inspection of the standardized residual matrix
less harmonious and the statistical significance of regression coefficients.
situations. There were missing values for some of the variables, vary-
Organization The degree of 9 0.75 ing from n = 1 to n = 21. Complete case analysis was used
structure, routines, to handle missing data.
and assignment of
roles in the family,
as well as the
family’s ability to Results
resolve problems.
Parenting (CRPR) Of the 450 families approached, 55.7% returned the
Restrictiveness Parents’ tendency to 22 0.84 questionnaire. The majority of questionnaires were
confine behaviour
completed by the mother (n = 227; 90.4%) and the
within certain
specified limits. remaining 24 (9.6%) questionnaires were completed by
Nurturance Interaction between 28 0.81 the father. The study sample consisted of 251 children;
parent and child in just over half (50.6%) were girls. The mean age of the
which parent children was 6.6 yr 0.8 (mean SD) on the date of
responds to the completing the questionnaire. The mean dmft of chil-
child’s needs. dren was 4.6 3.2 (range: 0–12) and only 15.9% of
CRPR, Child Rearing Practices Report (21); GVL, Gezinsvragen- the children in the sample had a dmft of 0. Of the 251
lijst (Family Questionnaire) (14). children, 107 (43.7%) had elevated or high scores for4 de Jong-Lenters et al. Fig. 1. Schematic illustration of the hypothesized path model. Arrows imply that a variable has an influence on another variable; round connecting lines imply that variables are associated. The a priori hypotheses of the path model are as follows. (i) dmft = (b1 • age toothbrushing was started) + (b2 • toothbrushing frequency) + e1. (ii) Age toothbrushing was started = (b3 • parenting restrictiveness) + (b4 • parenting nurturance) + (b5 • family functioning responsiveness) + (b6 • family functioning communication) + (b7 • family functioning organization) + e2. (iii) Toothbrushing frequency = (b8 • parenting restrictiveness) + (b9 • parenting nurturance) + (b10 • family functioning respon- siveness) + (b11 • family functioning communication) + (b12 • family functioning organization) + (b13 • externalizing behaviour problems) + e3. (iv) Externalizing behaviour problems = (b14 • parenting restrictiveness) + (b15 • parenting nurturance) + (b16 • family function- ing responsiveness) + (b17 • family functioning communication) + (b18 • family functioning organization) + e4. (v) Parenting restrictiveness = (b19 • education level (mother)) + (b20 • country of birth (mother)) + e5. (vi) Parenting nurturance = (b21 • education level (mother)) + (b22 • country of birth (mother)) + e6. (vii) Family functioning responsiveness = (b23 • education level (mother)) + (b24 • country of birth (mother)) + e7. (viii) Family functioning communication = (b25 • education level (mother)) + (b26 • country of birth (mother)) + e8. (ix) Family functioning organization = (b27 • education level (mother)) + (b28 • country of birth (mother)) + e9. externalizing behaviour problems. Table 2 describes the toothbrushing was not significantly associated with distribution of sociodemographic variables, oral health mean dmft. Children from poor functioning families behaviours, and family functioning and parenting vari- (clinical scores) in terms of responsiveness, communica- ables in the study sample. tion, and organization, and children of parents with The mean dmft in children with elevated/high scores restrictive parenting behaviours, had a significantly for externalizing behaviour problems was 4.9 3.1, higher dmft. No statistical association between parent- compared with 4.2 3.2 in children with average ing in terms of nurturance and dmft was found. With scores. Poisson regression showed that children with respect to externalizing behaviour problems, no signifi- elevated/high scores for behaviour problems had 19% cant associations with the mother’s education level, the greater caries experience than children with average mother’s country of birth, and toothbrushing beha- scores for behaviour problems [incidence risk ratio viours were found. Children from poor functioning (IRR) = 1.19, 95% CI: 1.06–1.34, P = 0.004]. This families in terms of communication and children of association did not remain statistically significant after parents who reported low levels of nurturance were sig- adjustment for child’s age, gender, and the mother’s nificantly more likely to have ‘high/elevated’ scores for education level and country of birth (IRR = 1.11, 95% externalizing behaviour problems. Externalizing beha- CI: 0.99–1.34, P = 0.080). viour problems were not associated with family func- Table 3 shows the univariate associations of sociode- tioning in terms of responsiveness and organization, or mographic, behavioural, and family-related factors with with restrictive parenting. dmft and with child behaviour problems. Children Analysis of the hypothesized path model of Fig. 1 whose mother had a higher level of education had sig- indicated poor fit: v2/d.f. ratio = 147.89/27, P < 0.001; nificantly lower levels of dmft, while immigrant children RMSEA = 0.145, 95% CI: 0.123–0.169; SRMR = had a significantly higher dmft. Children who started 0.098, and CFI = 0.428. The model was subsequently toothbrushing after the age of 2 yr had 33% higher modified according to the following steps. Of the family levels of dmft than children who started toothbrushing functioning and parenting variables, regression coefficients before they were 1 yr old. The frequency of showed that only restrictiveness remained associated with
Dental caries and behaviour problems 5
Table 2 variables and dmft were not statistically significant, yet it
Description of the study sample was decided to retain these paths for conceptual reasons.
The resulting numerical solutions of the revised model were
Characteristics Value (see Table 4):
Age (yr) 6.6 0.8 (4.6–8.5)
Gender (i) dmft = (0.06 • age toothbrushing was started) +
Boy 124 (49.4) (0.06 • toothbrushing frequency);
Girl 127 (50.6) (ii) age toothbrushing was started = 0.14 • parenting
Educational level (mother) restrictiveness;
Lower education 62 (24.7)
(iii) toothbrushing frequency = ( 0.21 • parenting
Intermediate education 119 (47.4)
Higher education 70 (27.9) restrictiveness) + (0.02 • externalizing behaviour prob-
Country of birth (mother) lems);
The Netherlands 208 (82.9) (iv) externalizing behaviour problems = ( 0.10 • par-
Other 43 (17.1) enting nurturance) + (0.21 • family functioning com-
Age toothbrushing was started munication);
2 yr 19 (7.7)
(mother);
Toothbrushing frequency (vi) parenting nurturance = 0.11 • education level
1 time or less a day 63 (25.2) (mother); and
2 times a day or more 187 (74.8) (vii) family functioning communication = 0.20 • edu-
Family functioning – responsiveness cation level (mother).
Normal 230 (91.3)
Subclinical 19 (7.5)
Clinical 3 (1.2)
Family functioning – communication Discussion
Normal 204 (82.6)
Subclinical 32 (13.0) This study found that children with elevated or high
Clinical 11 (4.5) externalizing behaviour problems had significantly more
Family functioning – organization dental caries experience, but this association did not
Normal 206 (82.4) remain statistically significant after adjustment for
Subclinical 32 (12.8) sociodemographic characteristics. This study presented
Clinical 12 (4.8) a valid model of possible direct and indirect pathways
Parenting – restrictiveness
Low 116 (50.4)
between sociodemographic factors, parenting and fam-
High 114 (49.6) ily functioning factors, oral health behaviours, external-
Parenting – nurturance izing behaviour problems, and dental caries in children.
Low 128 (51.6) In this model, a lower maternal education level was
High 120 (48.4) associated with higher levels of restrictive parenting,
Data are given as mean SD (range) or n (%).
lower levels of nurturance, and a higher likelihood of
dysfunctional family communication. Higher levels of
restrictive parenting were associated with a lower tooth-
brushing frequency and a higher age at which tooth-
toothbrushing behaviours, and only nurturance and family brushing was started, which, in turn, were associated
functioning, in terms of communication, were associated with greater dental caries experience (but that was not
with externalizing behaviour problems. This implied that statistically significant). Furthermore, lower levels of
retaining only these paths and excluding the responsiveness nurturance and poorer family functioning in terms of
and organization variables could improve model fit. Regres- communication were associated with a higher likeli-
sion coefficients also revealed that the mother’s country of hood of externalizing behaviour problems. Externaliz-
birth could be omitted when the mother’s education level ing behaviour problems were subsequently linked to
was included. Furthermore, inspection of the standardized dental caries via a direct correlation and through a
residual matrix indicated that the fit could be improved by nonsignificant indirect path via toothbrushing fre-
adding a direct path between the mother’s education level quency. In addition, lower maternal education was
and dmft. Although a direct link is evidently not plausible, a directly associated with greater dental caries experience.
conceptual rationale for this modification is that the influ- The model suggests that it is plausible that external-
ence of education level on dental caries acts via several izing behaviour problems and dental caries are associ-
other intermediary variables that were not included in this ated because toothbrushing is more challenging in
model. Finally, the model could be improved by adding a children with externalizing problem behaviour. The
correlation between externalizing behaviour problems model also provides support for the indirect hypothesis
and dental caries. Application of these modifications that externalizing behaviour problems and dental caries
resulted in a revised model (Fig. 2), which yielded good fit: are associated because family environmental factors,
v2/d.f. ratio = 18.35/15, P = 0.245; RMSEA = 0.032, 95% such as low maternal education and negative aspects of
CI: 0.000–0.076; SRMR = 0.046, and CFI = 0.964. The parenting and family functioning, coexist in the same
paths between externalizing behaviour problems and tooth- families, which may exert an influence on child beha-
brushing frequency, and paths between toothbrushing viours in general. However, the inclusion of a direct6 de Jong-Lenters et al.
Table 3
Univariate associations between sociodemographic, behavioural, and family-related factors and decayed, missing, and filled primary
teeth (dmft; Poisson regression) and externalizing behaviour problems (logistic regression)
dmft Externalizing behaviour problems
IRR (95% CI) P-value* OR (95% CI) P-value†
Sociodemographics
Educational level (mother)
Lower education 1 1
Intermediate education 0.75 (0.66–0.86)Dental caries and behaviour problems 7
Fig. 2. Revised path model. Arrows imply that a variable has an influence on another variable; round connecting lines imply that
variables are associated. Values in circles represent unexplained variance. *P < 0.05.
Table 4
Standardized and unstandardized path coefficients of the revised model
Standardized path
Effects coefficient (b) Unstandardized path coefficient SE 95% CI P-value
Dental caries (dmft)
Education level (mother) 0.31 1.35 0.29 1.92 to 0.798 de Jong-Lenters et al.
sample: referral is often triggered by treatment failures. reported with problem behaviour, childhood obesity,
Therefore, the high level of caries-active children could and an unhealthy diet (29). The question that arises is
have interfered with differentiation in the caries-active whether negative parenting also makes children less
group in all the constructs measured. In addition, the likely to comply with oral health behaviours imposed
modest sample size (n = 251) and the relatively high by the parents.
non-response rate (44%) has resulted in very low num- Poor family functioning in terms of communication
bers of children with poor family functioning. This may and low levels of nurturance were both related to child
have obscured the demonstration of statistically signifi- behavioural problems. These interactions are reciprocal
cant associations (type II errors) and also limited the and may create a vicious cycle in which difficult-to-
power and the number of variables and paths that manage children elicit more negative and ineffective
could be explored in the structural equation model. parental treatment. Less favourable parenting and fam-
Another limitation is that only one parent, often the ily functioning may, in turn, contribute to the develop-
mother, completed the questionnaire. Therefore, data ment of even higher levels of child problem behaviours
on child behavioural problems, family functioning, and (30). This bidirectional relationship may have a syner-
parenting solely relied on the view, perceptions, and gistic effect on the risk of developing dental caries
reporting of one parent. However, the original authors because both are risk factors in the development of the
who developed the ‘Family Questionnaire’ evaluated disease and are likely to intensify each other.
the interparental agreement, and they concluded that In conclusion, this study found that externalizing
mothers and fathers report comparable opinions about behaviour problems were associated with greater dental
their family functioning and parenting (14). This is in caries experience in children, although this association
line with previously reported literature (27). did not remain statistically significant after adjustment
The measurement of oral hygiene behaviours using for sociodemographic factors. This study provided
self-report questionnaires also had its limitations. The some support for a direct path between child behaviour
oral health behaviours reported in this study may not problems and dental caries via toothbrushing beha-
have been an accurate reflection of actual behaviours viour. Yet, the findings also imply that the restrictive-
because parents could have given socially desirable ness and warmth of parenting and the communication
responses and behaviours were measured at a single of the family probably play an indirect role in the asso-
point in time, and they can change over the years. Par- ciation between children’s behavioural problems and
ticularly in this sample, children received dental care in dental caries experience.
a specialized paediatric centre and therefore they prob- The findings of this study suggest that parent and
ably received oral hygiene instructions and guidance. family factors, such as poor family functioning and
As a result, oral health behaviours at the time of mea- strict and harsh parenting, should receive more atten-
surement may have improved since the time that dental tion when developing tailored caries-preventive
caries had developed, or parents may have over- approaches, particularly when children have behaviour
reported good behaviours. This may explain why no, problems. The reciprocal association between family
or only weak, associations between oral hygiene beha- factors and child behaviour problems should be consid-
viours and dental caries or child behaviour problems ered because this may be a complicating factor in
were found. establishing dentally healthy behaviours. Given the
Conceptually, oral health behaviour may play an ineffectiveness of health education by teaching knowl-
important role in explaining the relationship between edge alone, the needs of the patient and the family as a
behaviour problems and dental caries. For example, whole should be considered. More research is needed
parents may find it more difficult to maintain healthy to evaluate preventive interventions that target these
behaviours if the child shows resistance towards the factors. Education for dental students is lacking in this
rules and structures provided by their parents. Commu- field, so in the event that positive findings are identified
nication may also be more challenging in children with in prospective interventions, a paradigm shift will be
externalizing behaviour problems, which could be required to educate a new generation and to introduce
reflected in the way that parents deal with their chil- the consideration of these factors into daily practice.
dren’s wishes or demands with regard to – for example
– sugary snacks (15). Acknowledgements – The authors would like to thank Nanda
Children of restrictive parents had significantly Greving-Visser and the rest of the team of Cleyburch junior for
helping with the data collection and Erica Polak for her useful
greater dental caries experience, in line with findings of suggestions.
previous studies (15, 16). The finding of strict parenting
being a risk factor for dental caries is counterintuitive
Conflicts of interest – The authors declare that they have no con-
because strictness may be expected to further the estab- flict of interest.
lishment of routines, daily structures, and living in
accordance with rules. However, similar findings have
been found in the literature. Strict, harsh, and coercive
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