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International Journal of Paediatric Dentistry 2002; 12: 101108

Influence of parents oral health behaviour on oral health

status of their school children: an exploratory study
employing a causal modelling technique
Blackwell Science Ltd

M. OKADA1, M. KAWAMURA2, Y. KAIHARA1, Y. MATSUZAKI1,

S. KUWAHARA1, H. ISHIDORI1 & K. MIURA1
1Department

of Paediatric Dentistry and 2Department of Preventive Dentistry,

Hiroshima University Faculty of Dentistry, Minami-ku, Hiroshima, Japan

Summary. Objectives. The aim of this study was to examine the simultaneous interrelationships between parents oral health behaviour and the oral health status of their
school children.
Sample and methods. Subjects comprized 296 pairs of parents (mother or father) and
their children at an elementary school in Hiroshima. The childs dental examination
was performed using the World Health Organization (WHO) caries diagnostic criteria
for decayed teeth (DT) and filled teeth (FT). The Oral Rating Index for Children (ORIC) was used for the childs gingival health examination. Hiroshima University Dental
Behavioural Inventory (HU-DBI) was used for the assessment of the parents oral health
behaviour. A parent child behavioural model was tested by the linear structural relations
(LISREL) programme.
Results. There was a significant correlation between DT and ORI-C (r = 0168; P < 001).
Correlation was found between ORI-C and oral health behaviour in children (OHB-C)
(r = 0182; P < 001). OHB-C was significantly associated with the HU-DBI (r = 0251;
P < 0001). The hypothesized model after some revisions was found to be consistent
with the data (2 = 13, d.f. = 6, P = 097; Goodness of Fit Index = 0999). Parents
oral health behaviour affected their childrens oral health behaviour (P < 0001). Childrens oral health behaviour affected their DT through its effect on gingival health level.
Parents oral health behaviour also had a significant direct effect on their childrens
DT (P < 005). Childrens grade affected both DT and their oral health behaviour.
Conclusions. Parents oral health behaviour could influence their childrens gingival
health and dental caries directly and/or indirectly through its effect on childrens oral
health behaviour.

Introduction
Adoption of consistent behavioural habits in childhood
takes place at home, with the parents, especially the
Correspondence: Dr Mitsugi Okada, Department of Paediatric
Dentistry, Hiroshima University Faculty of Dentistry, 12-3
Kasumi, Minami-ku, Hiroshima 7348553, Japan. E-mail:
mitsugi@hiroshima-u.ac.jp
2002 BSPD and IAPD

mother, being the primary model for behaviour [1].

To prevent dental caries and gingivitis, a mothers
support is essential. Sasahara et al. [2] showed that
mothers gingival condition, as a result of oral
health behaviour, was associated with the prevalence
and severity of dental caries in their 3-year-old
children. Sarnat et al. [3] also reported that, at the
ages of 5 to 6 years, the more positive the mothers
attitude regarding her child, the fewer caries the
101

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M. Okada et al.

child had, the better the childs oral hygiene, and

the more dental treatment the child received. There
are few studies of parents influence on gingival
health of their school children by stage of childhood
development. It has been reported that, although
school children believed that appropriate behaviours
could promote health, they did not develop an
awareness of this relationship until the third and
fourth grade [4]. From the point of view of Banduras
social cognitive theory [5], overt behaviours of
significant others represent important sources of
social influence.
Socialization to oral health behaviours may be
considered a modelling process in which children
imitate the behaviour of their parents, who are available and who provide valued role models for their
offspring [5]. Parental modelling has proved to be
a powerful means of establishing novel behaviours
among children, such as tooth brushing behaviour
[6], but has rarely been studied as a behavioural
factor with simultaneous interrelationships among
variables of oral diseases.
Linear structural relations (LISREL) analysis
provides an opportunity to evaluate an entire set of
relationships at the same time [7]. It has several
advantages over traditional statistical methods, particularly as it explores the causal links rather than
mere empirical relationships between variables. In
addition, knowledge of the methodological adequacy
of the data-gathering process and the quality of measurement instruments can be directly incorporated
into LISREL models by estimating the proportion of
the variance in an indicator that is error variance.
The aim of the present study was to examine the
simultaneous interrelationships between parents
oral health behaviour and oral health status of their
school children by using the LISREL.
Theoretical model
The construction of a hypothesized model (Fig. 1)
is based on the findings of earlier studies [16,813]
of factors affecting oral health. It was hypothesized
that parents oral health behaviour is linked to oral
health status (dental caries and gingivitis) of their
school children directly, or indirectly through childrens oral health behaviour. It was hypothesized
that dental caries of school children are causally
linked to their gingival health level, which reflects
oral hygiene status (self-care level). Children with
poorly controlled oral hygiene would suffer signi-

Fig. 1. Construction of a hypothesized model. Influence of

parents oral health behaviour on both oral health behaviour and
oral health status of their school children.

ficantly more from tooth decay than those with good

control. It was hypothesized that childrens grade
and decayed teeth had direct effects on the number
of filled teeth.
Sample and methods
The study was conducted at an elementary school
in 1998 among a sample of 712-year-old children
in Hiroshima, Japan. Consent for this survey was
received from their parents prior to the study through
their schoolteachers. The parent (either mother or
father) was asked to answer a questionnaire about
the oral health behaviour of his/her child (OHB-C).
Five items in the OHB-C concerned daily brushing,
brushing frequency, use of floss, regular dental visit
and regular snack-time (Table 1). For each item, the
appropriate response was determined through
consideration of current information about the topic
addressed by the item. A higher score indicates
better dental health behaviour of children. The
Hiroshima University Dental Behavioural Inventory
(HU-DBI) [14] was used for the assessment of
parents oral health behaviour. The maximum score
of the HU-DBI was 12. A higher score indicates
better oral health behaviour. It has been shown to
be internally consistent (Cronbachs alpha = 076)
[15]. The HU-DBI had a good testretest reliability
(073) over a 4-week period [16]. Three hundred and
eight parents (mother or father) responded to this survey. The participation rate was 76%. Ten parents did
not complete the HU-DBI questions. The mother to
father ratio in the participants was 13 : 2. The mean
age of the parents was 377 years (standard deviation:
44 years).

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Parents influence childrens oral health

103

Table 1. Percentage distribution of the parents with agree responses for each item on childrens oral health behaviour (OHB-C).
No.
1.
2.
3.
4.
5.

Item descriptions
My
My
My
My
My

child
child
child
child
child

brushes his/ her teeth every day (A)

brushes his/ her teeth more than twice a day (A)
never uses dental floss (D)
goes to see the dentist periodically (A)
has a snack at a certain time every day (A)

Boys
(n = 148)

Girls
(n = 148)

Chi-square
test

Total
(n = 296)

81
71
84
26
49

88
83
84
32
43

NS
*
NS
NS
NS

84
77
84
29
46

In the calculation of the OFIB-C: (A)One point is given for each of these agree responses. (D)One point is given for each of these
disagree responses. Cronbachs alpha = 051. Significant differences between boys and girls; *P < 005, NS = not significant.

Oral examinations took place at school for all

children, with the exception of two who were absent
from school. The ORI-C, which consists of five categories (+2, +1, 0, 1, 2), was used for gingival
health examination as previously described [17]. It
was performed by a paediatric dentist (MO), using
natural light with children seated in a chair, with a
set of standard photographs of each level of the
scale to maintain consistent standards. Next, the
children were dentally examined by three specialist
paediatric dentists (YK, SK, HI) using the World
Health Organization (WHO) caries diagnostic criteria for DMFT (decayed teeth, missing teeth, filled
teeth) [18]. The examination took place with the
subjects in a supine position, using an artificial light,
a dental explorer and a dental mirror. The mean percentage agreement among the dentists was more
than 90% (YK versus SK 92%, SK versus HI 95%,
HI versus YK 91%) for the inter-examiner reproducibility for DMFT criteria in a sample of 20 elementary school children. Subjects included 296 pairs
out of 406 parents and their children (213 boys and
193 girls). Thirty-nine fathers and one person who
did not report his/her sex distinction were included
among 296 respondents.
Descriptive statistics (means and standard deviations) and correlation coefficients were used to provide preliminary information about the associations
between six selected parameters. All paths connecting
the error components were set to unity. The overall
fit was assessed by four measures: the chi-square
test, the goodness of fit index (GFI), the adjusted
goodness of fit index (AGFI) and the root mean
square error of approximation (RMSEA). In this
study, the quality of model fit was considered reasonable, with the probability of a greater chi-square
value than the obtained values not less than 005,
GFI (AGFI) greater than 090 and, after standardization, RMSEA less than 005. Statistical analyses

were conducted using SPSS 100 J and Amos 40

(SPSS Inc., Chicago, Illinois, USA; SmallWaters
Co., Chicago, Illinois, USA).
Results
Table 1 presents the percentage distribution of the
parents with agree responses for each item on the
OHB-C, for the total sample, and boys and girls
separately. More than 80% of the parents reported
that their child brushed his/ her teeth everyday.
However, 84% stated that their child had never used
dental floss. Only 29% reported that their child went
to see the dentist periodically. Table 2 shows
descriptive statistics of and correlation coefficients
among six selected variables. The mean scores of
DT, FT, OHB-C and HU-DBI were 037, 193, 250
and 500, respectively. Cronbachs alpha was 051
for the OHB-C. There was a significant correlation
between DT and ORI-C (r = 0168; P < 001).
Correlation was found between ORI-C and OHB-C
(r = 0182; P < 001). OHB-C was significantly
associated with HU-DBI (r = 0251; P < 0001).
When the initial model was estimated, the chisquare was 139 ( d.f. = 6, P = 003), suggesting that
the model did not fit the data. LISREL diagnostic
information led us to allow the childs grade to
affect his/ her oral health behaviour. Although no
direct path was initially hypothesized from childs
grade to DT, LISRELs modification index also
suggested this, so that the path linking grade to DT
was added. With these changes, the overall revised
model was judged to be satisfactory (2 = 13;
d.f. = 6, P = 097, GFI = 0999, AGFI = 0995,
RMSEA = 0000). The outline of our final model is
given in Fig. 2. Parents oral health behaviour had
a negative direct path to DT (014, P < 005) and
also had an indirect effect on childs gingival health
through childs oral health behaviour. It was found

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M. Okada et al.

Table 2. Descriptive statistics of and correlations among six selected variables.

n
Mean
SD
Grade
DT
FT
ORI-C
OHB-C
HU-DBI

Grade

DT

FT

ORI-C

OHB-C

HU-DBI

296
351
172
1
0139*
0466***
0052
0158**
0011

296
037
102

296
193
192

296
008
092

296
250
125

296
500
216

1
0119*
0168**
0073
0153**

1
0005
0103
0002

1
0182**
0079

1
0251***

Grade = childs school grade; DT = the number of decayed teeth; FT = the number of filled teeth; ORI-C = oral rating index for children;
OHB-C = childs oral health behaviour; HU-DBI = parents oral health behaviour. Pearsons correlation coefficient (*P < 005, **P < 001,
***P < 0001).

Fig. 2. Outline of the final model. Childs

grade = childs school grade; decayed
teeth = childs number of decayed teeth;
filled teeth = childs number of filled teeth;
gingival health = score assessed by the
ORI-C; childs oral health behaviour =
OHB-C score; parents oral health behaviour = HU-DBI score. The overall fit was
assessed by four measures: chi-square test,
GFI (goodness of fit index), AGFI (adjusted
goodness of fit index) and RMSEA (root
mean square error of approximation). The
standardized regression weights are displayed
near single-headed arrows in the path diagram.
*P < 005, **P < 001, ***P < 0001.

that childs gingival health had a negative effect on

DT (015, P < 001) and that DT had a negative
effect on FT (019, P < 0001). Childs grade had
a positive effect on FT (049, P < 0001). Childs
oral health behaviour did not have any significant
effect on DT. In addition, the direct effect of
parents oral health behaviour on childs gingival
health was not significant. Further, the sign of the
coefficient for the association between childs grade
and oral health behaviour was negative (016,
P < 001). There were some striking differences for
the values of model parameters for the genders
(Figs 3 and 4), although the same model fitted the
data well for boys and for girls. For boys, parents
oral health behaviour had a significant effect on DT
(017, P < 005), whereas for girls it was not significant. Conversely, for boys their gingival health did
not have any significant effect on DT, whereas for
girls it was significant (018, P < 005).

Discussion
The results of this study showed that parents oral
health behaviour had a direct influence on their
childrens number of decayed teeth. Furthermore,
parents oral health behaviour had an indirect effect
on gingival health level of their children through
childrens own oral health behaviour. The finding is
in agreement with those of Sasahara et al. [2], Sarnat
et al. [3] and strom & Jakobsen [9], who reported
a significant correlation between parental oral health
behaviour and their childs oral health behaviour.
The findings of this study support the importance
of the continued emphasis on parents self-care
strategies for not only their oral health but also their
childrens oral health. Sallis & Nader [8] presented
a conceptual model of family influences on health
behaviour. The model comprizes four major components: (i) the family environment and interrelationships

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Parents influence childrens oral health

105

Fig. 3. Outline of the final model (boys). Illustration

legends are the same as those in Fig. 2.

Fig. 4. Outline of the final model (girls). Illustration

legends are the same as those in Fig. 2.

between health behaviours of the family members; (ii) the antecedents and consequences of
health behaviours; (iii) the influential mechanisms,
namely response facilitation, observational learning
and observation of consequences; and (iv) external
influences.
strom & Jakobsen [9] also reported that there
were statistically significant associations of use of
dental floss, tooth brushing and drinking of nonsugared mineral water among parents and their
adolescent offspring. Stewart et al. [10] showed that
there was a statistically significant increase in selfefficacy for brushing and flossing following psychological interventions to improve oral hygiene
behaviour. In Japan, most people do not know how
to use dental floss [19,20]. Although the role of
social cognitive variables on oral hygiene behaviour
(the daily removal of dental plaque by brushing and
flossing) has received little research attention in Japan,
children who have been encouraged in their preventive health behaviour may have self-efficacy during
growth and development. In this study, parents oral
health behaviour had a direct effect on DT for boys,
whereas for girls it had an indirect effect on DT
through their oral health behaviour and gingival

health. There may be different mechanisms for causal

models in boys and girls. School children as a whole
who consciously try to maintain good oral health,
then, do in fact practice good health behaviours.
Some modifications to our initial model were suggested from the Amos programme [21]. For example, the path from childrens grade to their oral
health behaviour was added as it was theoretically
plausible to consider that childrens educational
level might explain and influence their brushing
behaviour. In the current study, childrens grade was
negatively linked to their oral health behaviour, the
opposite to what was expected. This path was necessary to provide a good fit to the data. One possible
reason for finding a negative path from grade to oral
health behaviour might be that some children have
not brushed and flossed their teeth willingly. For
most Japanese mothers, the extent to which they
check up on their childrens teeth and oral hygiene
gradually decreases until the child starts elementary
school [22]. Another reason might be that dentists
generally treat their patients when they have dental
pain and have not encouraged their patients brushing and flossing, although behavioural management
is considered as the treatment of choice [23].

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M. Okada et al.

There are limitations in the methods and results of

this study. First, parents educational level and social
class were not accounted for in the model. Eccleston
[24] wrote, however, In Japan there are less significant social or class divisions. There is believed to
be less socio-economic variation in Japanese culture
than in other countries. Approximately 95% of people
go to senior high school and most people would be
described as coming from middle class backgrounds.
All people in Japan are covered under medical and
dental insurance. Questions such as personal finance
or educational level are considered sensitive issues
to Japanese people; including such questions would
be likely to reduce the participation rate dramatically. Also, items with regard to fluoride were not
included. One of the reasons was that the items on
fluoride seemed to have a problem of face validity
in Japan: fluoride application has so far reached only
a small percentage of the Japanese population [25]
and people appeared less well-informed on the benefits of water fluoridation [26].
Secondly, the participation rate of the present
study was not high. Parents having negative attitudes
toward oral health care would be unlikely to have
responded to the questionnaire. Therefore, the real
state of parentchild relations may differ to some
extent from that shown in the model. Thirdly, the
internal reliability of the OHB-C was not adequate
to assess childrens oral health behaviour. Further
research is needed to examine and develop its metric
properties of reliability and validity. Fourthly, it might
be better to investigate the influences of fathers and
mothers oral health behaviour separately. When the
data for 256 mothers were analysed, the causal relationship was almost the same as that in Fig. 2
(results not shown). This study, however, was not
intended to clarify differences in parental background. It is common in Japan for mothers with
school-age children not to work outside the home.
Ozawa [27] reported that Japans labour market is
still shaped by the uniform assumption that men go
outside to work while women maintain the home.
The mother to father ratio in the participants may
reflect these circumstances. Fifthly, in cross-sectional
studies, the causal interpretation of LISREL (like
any other multivariate statistical method) is fundamentally incorrect. Prospective, longitudinal research
employing causal modelling techniques might be
needed to clarify the nature of these relationships.
Despite the above-mentioned shortcomings of this
study, it can be seen that gingival health status of

school children and their parents oral health behaviour have significant direct relationships with the
childrens dental caries. Parents oral health behaviour could influence their childrens gingival health
and dental caries directly, or indirectly through its
effect on childrens oral health behaviour, although
differences in cultural background and education
between countries may have contributed to the trend
seen in the results of this study.
Rsum. Objectifs. Cette tude a eu pour objectif
dexaminer les interrelations simultans entre
lhygine buccale des parents et ltat de sant
buccale de leur enfant scolaris.
Mthodes. Sujets comprenant 296 paires parents
(pre ou mre) et leurs enfants dans une cole
lmentaire de Hiroshima. Lexamen dentaire de
lenfant a t ralis laide des critres diagnostiques de carie de lOrganisation Mondiale de la
Sant (OMS) pour les dents caries (DT) et obtures
(FT). Lindice dvaluation buccal pour les enfants
(ORI-C) a t utilis pour lexamen de la sant
gingivale des enfants. Le HU-DBI (Evaluation de
comportement dentaire de lUniversit de Hiroshima)
a t utilis pour valuer les habitudes dhygine
buccale des parents. Un modle comportemental
parent-enfant a t test par le programme LISREL
(relations structurelles linaires).
Rsultats. Il y avait une corrlation significative
entre DT et ORI-C (r = 0,168; p < 0,01). Une corrlation a t retrouve entre ORI-C et les habitudes
de sant buccale des enfants (OHB-C) (OHB-C)
(r = 0,182; p < 0,01). OHB-C tait significativement
associ HU-DBI (r = 0,251; p < 0,001). Le modle
suppos aprs quelques rvisions tait reliable aux
donnes data (2 = 1,3, df = 6, p = 0,97; Indice
dadquation = 0,999). Les habitudes de sant
buccale des parents avaient galement un effet direct
sur les habitudes de sant buccale des enfants
( p < 0,001). Les habitudes de sant buccale des
enfants affectaient leurs DT par leur effet sur ltat
de sant gingivale. Les habitudes de sant buccale
des parents avaient aussi un effet significatif direct
sur les DT de leurs enfants ( p < 0,05). Les habitudes
de sant buccale des parents affectaient les habitudes de sant buccale de leurs enfants ( p < 0,001).
Le grade des enfants affectait la fois le DT et leurs
habitudes de sant buccale.
Conclusions. Les habitudes de sant buccale des
parents pourraient avoir une influence directe sur la
sant gingivale et les caries de leurs enfants et/ou

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Parents influence childrens oral health

indirecte travers leurs effets sur les habitudes de

sant buccale de ceux-ci.
Zusammenfassung. Ziele. Untersuchung der Wechselbeziehung zwischen elterlichem Mundgesundheitsverhalten und dem Mundgesundheitszustand
des Kindes.
Methoden. Die Stichprobe umfasste 296 Elternpaare
(Mutter oder Vater) und deren Kinder an einer
Grundschule in Hiroshima. Die Untersuchung der
Kinder erfolgte nach WHO-Kriterien aufgeschlsselt
in karise Zhne (DT) und Zhne mit Restaurationen
(FT). Der Oral Rating Index fr Kinder (ORI-C)
wurde zur Untersuchung der Gingiva herangezogen.
Das Hiroshima Universitt Dental Behaviour Inventory (HU-DBI) wurde benutzt zur Feststellung des
Mundgesundheitsverhaltens der Eltern.
Eine Eltern-Kind-Verhaltensmodell wurde mit dem
LISREL Programm getestet.
Ergebnisse. Es zeigte sich eine signifikante Korrelation zwischen DT und ORI-C (r = 0.168; p < 0.01)
und zwischen ORI-C und OHB-C (r = 0.182; p < 0.01)
sowie zwischen OHB-C und HU-DBI (r = 0.251;
p < 0.001). Das angenommene Modell war nach
einigen nderungen vereinbar mit den Daten (2 = 1.3,
df = 6, p = 0.97; Goodness of Fit Index = 0.999).
Das Mundgesundheitsverhalten der Eltern beeinflusste das Mundgesundheitsverhalten der Kinder
( p < 0.001). Das Mundgesundheitsverhalten der
Kinder beeinflusste den DT-Wert durch den Effekt
auf die Gingiva. Das Mundgesundheitsverhalten der
Eltern hatte einen signifikanten direkten Einfluss auf
den DT-Wert ihrer Kinder ( p < 0.05). Die Klassenstufe beeinflusste sowohl DT als auch das Mundgesundheitsverhalten der Kinder.
Schlussfolgerungen. Das elterliche Mundgesundheitsverhalten knnte die Gingivagesundheit sowie
Kariesentstehung direkt beeinflussen oder indirekt
ber das Mundgesundheitsverhalten der Kinder.
Resumen. Objetivo. El objetivo de este estudio fue
el de examinar las relaciones simultneas entre las
conductas sobre la higiene oral de los padres y el
estado de salud oral de sus hijos/as en edad escolar.
Mtodos. Los sujetos comprendan 296 parejas de
padres (madre o padre) y sus hijos en una escuela
elemental de Hiroshima. El examen dental de los
nios se realiz usando el criterio diagnstico de
caries de la Organizacin Mundial de la Salud
(OMS) para dientes cariados (DC) y dientes obturados (DO). Se utiliz el Indice de valoracin oral

107

para nios (ORI-C) para examinar la salud gingival.

Se utiliz el Inventario de conducta oral de la Universidad de Hiroshima (HU-DBI) para analizar las
conductas sobre salud oral de los padres. Se prob
un modelo de comportamiento padre-hijo a travs
del programa de las relaciones lineales estructurales
(LISREL).
Resultados. Exista una correlacin significativa
entre DC y ORI-C (r = 0,168; p < 0,01) Se encontr
correlacin entre ORI-C y Comportamiento sobre
higiene oral en los nios (OHB-C) (r = 0,182;
p < 0,01) El OHB-C se asoci significativamente
con el HU-DBI (r = 0,251; p < 0,001)
El modelo hipottico, prob ser consistente con
los datos, despus de algunas revisiones (2 = 1,3;
do = 6; p = 0,97; Indice de Bienestar = 0,999) La
conducta sobre la salud oral de los padres afectaba
la conducta sobre la salud oral de sus hijos
( p < 0,001). La conducta sobre salud oral de los nios
afectaba su DO y tambin a los niveles de salud
gingival. Las conductas de salud oral de los padres
tambin tenan un efecto directo sobre el DO de sus
hijos ( p = 0,05). El grado de los nios afectaba tanto
a su DO como a su conducta de higiene oral.
Conclusiones. La conducta sobre la higiene oral de
los padres puede influir en la salud gingival y caries
dental de sus hijos directa o indirectamente a travs
de sus efectos en la conducta de higiene oral de sus
hijos.

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