International Dental Journal 2020; 70: 100–107

SCIENTIFIC RESEARCH REPORT

doi: 10.1111/idj.12526

Oral health-related quality of life and caries experience of

Hong Kong preschool children
Duangporn Duangthip , Sherry Shiqian Gao, Kitty Jieyi Chen, Edward Chin Man Lo and
Chun Hung Chu
Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.

Objective: This study aimed to investigate the association between oral health-related quality of life (OHRQoL) and car-
ies experience of Hong Kong preschool children. Methods: Parents or primary caregivers of Hong Kong preschool chil-
dren were invited to complete a self-administered dental health questionnaire. The study children were examined in their
classrooms. The decayed, missing and filled primary teeth (dmft) index was used for documenting the caries status. The
questionnaire included the Chinese Early Childhood Oral Health Impact Scale (ECOHIS) and collected sociodemo-
graphic information on the parents and children. Logistic regression analysis was used to determine the association
between OHRQoL and caries experience of preschool children. Results: A total of 434 preschool children were invited
to participate in the study; 336 (77.4%) received a dental examination and returned a parental questionnaire. The mean
(SD) age of the study children was 4.7 (0.3) years. An OHRQoL impact (ECOHIS score of >0) for at least one item was
reported by 236 (70.2%) parents/caregivers of the children included in the study. The overall mean (SD) ECOHIS score
was 5.8 (6.2). A caries prevalence (dmft > 0) of 36.9% and a mean (SD) dmft score of 1.7 (3.2) were calculated for the
study children. In the final logistic regression model, children with a higher dmft score had a significantly higher chance
of having a poorer OHRQoL (OR = 1.20, 95% CI: 1.07–1.35, P = 0.002), whereas children’s sex, parent’s education
levels and the respondent’s relationship to the child were not associated with OHRQoL (P > 0.05). Conclusion: Caries
experience is associated with lower OHRQoL of Hong Kong preschool children.

Key words: Child, dental caries, early childhood caries, oral health, quality of life

experience, several epidemiological dental survey have

INTRODUCTION
been conducted. However, clinical outcome measures,
According to the American Academy of Pediatric Den- such as the decayed, missing and filled primary teeth
tistry, early childhood caries (ECC) is defined as the (dmft) index, represent only one physical aspect of den-
presence of one or more decayed (non-cavitated or cav- tal caries and do not reflect its impact on psychological
itated lesions), missing (from caries) or filled tooth sur- and social factors in the affected children6.
faces in any primary tooth in a child under the age of Following the definition of the World Health Orga-
six1. Dental caries in primary teeth was reported as the nization (WHO), ‘health’ is a stage of complete well-
12th most frequent medical condition in children, being and not just the absence of disease7. Evaluating
affecting approximately 560 million young children patients’ perceptions is vital when planning and allo-
globally2. A study published in 2017 reported that in cating appropriate resources to promote health and
Hong Kong, approximately half (55%) of preschool eradicate diseases8. Oral health-related quality of life
children have decayed teeth and almost all (93%) of (OHRQoL) is described as the impact of dental prob-
such teeth are unrestored or left untreated3. Compared lems on persons and patients, affecting factors such as
with a previous survey4, there has been no significant perception and self-esteem9. Several OHRQoL tools
improvement in the caries status among Hong Kong used in assessing patient-based outcomes and patients’
preschool children in the intervening 20 years5. To needs have been verified to be valid and reliable10.
monitor the severity and distribution of caries Nevertheless, young children usually lack the ability
100 © 2019 FDI World Dental Federation
 Oral health-related quality of life of children

to think in an abstract manner, which is the basis of 70%13. The ratio of children having an ECOHIS
health perceptions. Thus, parents or primary caretakers score of 0 to those having an ECOHIS score of >0
are considered to be their representatives in observing was anticipated to be 0.3/0.7, with 80% power (type
and describing the impacts and consequences of any II error set as 0.2) and the two-sided test at the 0.05
health problem. The Early Childhood Oral Health statistical significance level. It was estimated that of
Impact Scale (ECOHIS) is a parental proxy measure all children with caries experience, an impact on
used to assess the impact of oral diseases and dental- OHRQoL (ECOHIS score >0) would be demonstrated
treatment experiences on the quality of life of young by 75%, and the lowest ORs to be detected was set
children11. A recent study showed the Chinese ECO- as 2.514. Thus, at least 323 children in total (225 chil-
HIS to have high validity and reliability12. dren with an ECOHIS score of >0 and 98 children
As the last community-wide oral health survey on with an ECOHIS score of 0) were required. With an
OHRQoL and dental caries in preschool children was estimated participation rate of 80%, at least 404 chil-
conducted in Hong Kong in 201113 (PubMed search dren would need to be invited to take part.
carried out on 15 October 2018), updated patient-
based outcomes would be valuable for planning and
Questionnaire survey
implementing preschool oral health-care programmes.
It is unknown if socio-economic status and other A self-administered questionnaire was submitted to
effect modifiers may influence the impacts of ECC on the parents of the study children. The questionnaires
the quality of life of affected children. were completed at home before their children had
The aims of this study were to investigate the asso- received the dental examination. Thus, when complet-
ciation between caries experience and OHRQoL of ing the questionnaire, the respondents were unaware
preschool children and to investigate other risk factors of their child’s caries status. This questionnaire fea-
associated with their OHRQoL. tured two parts: (i) child and parents’ demographic
background, including child’s sex and age, mother’s
and father’s educational attainments and relationship
METHODS
of respondent to the child; and (ii) the Chinese ECO-
The present study received ethics approval from the HIS, 12 which contains two sections, as follows.
Institutional Review Board of the University of Hong • Child impact section (CIS)
Kong/Hospital Authority Hong Kong West Cluster (UW s Child symptoms – one item (toothache or oral

17–414). This study was performed in full accordance pain)

with ethical principles, including the World Medical s Child function – four items (having difficulty in

Association Declaration of Helsinki. An invitation letter eating, drinking and pronouncing words, and
describing the purpose and procedures of the study was missing school)
submitted to the parents of the preschool children. Writ- s Child psychology – two items (trouble sleeping

ten parental consent was obtained prior to implement- and frustrated/irritable)

ing the study. Inclusion criteria was the ability of s Self-image/social interaction – two items (avoid-

parents/caregivers of preschool children to read and ing smiling and avoiding talking with others)
write in Chinese. Exclusion criteria were preschool chil- • Family impact section (FIS)
dren who had major systemic illnesses or refused the s Parental distress – two items (upset and guilty)

dental examination. All participating children were s Family function – two items (taken day off and

examined in their kindergartens. The present study was affecting family economy).
carried out from 1 November 2017 to 30 April 2018. The response scores of the ECOHIS were as fol-
lows: score 0, never; score 1, hardly ever; score 2, oc-
casionally; score 3, often; score 4, very often; and
Study population and sample size calculation
score 5, don’t know. The score for each individual
A non-probability sampling technique was adopted. domain, section and in total were computed as a sum
We purposely selected six kindergartens that had not of the response scores. The response ‘don’t know’ was
participated in any research study and were located in recorded as missing. The sum ECOHIS score ranges
different districts from the list of participating kinder- from 0 to 52. Lower ECOHIS scores indicated lower
gartens in the dental outreach service funded by The impact on the quality of life of the child and his/her
University of Hong Kong in 2017–2018. The family.
G*Power 3.1.9.2 software (University of D€ usseldorf,
D€usseldorf, Germany) was used to estimate the sam-
Clinical examination
ple size. In a previous study among Hong Kong pre-
school children, an impact on OHRQoL (i.e., an Dental examinations were conducted in classrooms. A
ECOHIS score of >0) was reported for approximately single examiner (DD) had been trained and was
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Duangthip et al.

supervised by ECML and CCH, who are specialists in written informed consent was provided, prior to
dental public health. The examiner visually inspected implementation of the study, for 398 (91.7%). Thirty-
each child’s teeth using WHO Community Periodon- six children were absent on the day of examination
tal Index (CPI) dental probes and disposable mirrors and therefore, in total, 362 children received the den-
(MirrorLite; Kudos Crown Limited, Hong Kong) con- tal examination. Of these 362 children, 10 who did
nected with an illuminated intraoral handle. Clinical not return their questionnaires and 16 for whom more
data were recorded onto a paper sheet by a research than two items of the ECOHIS were not given a
assistant. The dmft index was adopted for document- score, were excluded. No significant difference was
ing the caries experience. A tooth was noted as observed regarding the caries prevalence of those 26
decayed (dt) when dentine caries was present, as filled children who did not return the questionnaire or for
(ft) when a permanent filling without caries was pre- whom more than two items of the ECOHIS were not
sent and as missing (mt) when a tooth had been given a score, compared with those for whom the
extracted because of dental caries. In the present instrument was answered properly (P = 0.185, chi-
study, dental caries was diagnosed at the cavitation square test). No significant difference was found
level based on the WHO criteria15. The consequences between those 16 children for whom more than two
of untreated caries were diagnosed using the four items of the ECOHIS were not given a score and
codes of the modified pufa index16: ‘p’ was noted those remaining in the study regarding demographic
when pulpal involvement was present; ‘u’ was background (age, gender, respondent and parents’
recorded if there was ulceration; ‘f’ was recorded if a education) and caries prevalence (P > 0.05) . Thus,
fistula was present; and ‘a’ was noted when an abscess 336 (77.4%) children were included in the study.
was present. Duplicate dental examinations on Among these children, eight missing values were
approximately 10% of the participants were con- detected. For each of these children, the mean ECO-
ducted on the same day of the dental examination to HIS score for the items given a score was calculated
evaluate intra-examiner reliability of caries assess- and inserted where scores were missing. Among the
ment. Between the duplicate examinations, at least 30
other children were examined so that the examiner
did not memorise the first recording. Table 1 Parent and child’s characteristics in the study
(n = 336)
Statistical analysis Parent and child’s characteristics Frequency Percentage

Data were cleaned and proofread before being trans- Parent’s demographics
Relationship of the respondent to the child
ferred to a computer database for storage, and were Mother 289 86.0
analyzed. Cohen’s kappa coefficient (j) was adopted to Other family member 47 14.0
assess intra-examiner reliability regarding the caries Mother’s education level
Up to junior secondary school 88 26.2
diagnosis. The chi-square test was used to investigate Secondary school 149 44.3
the relationships between categorical variables and the Post-secondary school/University 99 29.5
impact on OHRQoL. Multiple logistic regression anal- Father’s education level
Up to junior secondary school 89 26.5
ysis was used to determine the child factors (sex, age, Secondary school 146 43.4
dmft, modified pufa) and parental factors (father’s edu- Post-secondary school/University 101 30.1
cation level, mother’s education level, respondent’s Child’s demographics and caries status
Sex
relationship to a child) associated with ECOHIS. The Male 169 50.3
dependent variable was the impact of OHRQoL (hav- Female 167 49.7
ing at least one OHRQoL impact or an ECOHIS score Age (years)
4 264 78.6
of >0). Regarding the independent variables, caries 5 72 21.4
prevalence and modified pufa were continuous vari- Decayed teeth (dt)
ables in model A and dichotomous variables (yes/no) in dt = 0 213 63.4
dt ≥ 1 123 36.6
model B; all other variables in models A and B were Missing teeth (mt)
categorised as dichotomous. The backward stepwise mt = 0 336 100
procedure was performed until all variables in the final mt ≥ 1 0 0
Filled teeth (ft)
model were statistically significant (P < 0.05). The level ft = 0 323 96.1
of statistical significance was set at 0.05. ft ≥ 1 13 3.9
Decayed, missing or filled teeth (dmft)
dmft = 0 212 63.1
RESULTS dmft ≥ 1 124 36.9
Oral conditions of untreated caries (Modified pufa)
In total, 434 children attending the second year of six Modified pufa = 0 325 96.7
Modified pufa ≥ 1 11 3.3
selected kindergartens were invited to participate;
102 © 2019 FDI World Dental Federation
 Oral health-related quality of life of children

participants, 169 (50.3%) were boys. The mean age children with and without caries experience are
(SD) of the participants was 4.7 (0.3) years. Chil- shown in Table 3. The mean (SD) ECOHIS scores of
dren’s and parents’ demographic background and clin- children with and without caries experience were 7.4
ical characteristics are shown in Table 1. Of all (7.1) and 4.8 (5.5), respectively.
participants, 124 (36.9%) had caries experience Bivariate analysis of various factors related to the
(dmft ≥ 1): dmft, 1.6 (3.2); dt, 1.6 (3.0); and ft, 0.1 overall impacts, child impacts and family impacts are
(0.6). None of the study children had teeth missing as displayed in Table 4. In total, 79% of the children
a result of caries. Nearly all of the decayed teeth were who had caries experience reported an impact on
unrestored: the dt component accounted for 98.5% of OHRQoL. The dt and caries experience (dmft) were
the dmft index. Regarding intra-examiner reliability, statistically associated with the CIS and FIS of the
j = 0.95 for caries diagnosis. The prevalence of nega- ECOHIS and with the overall section (P < 0.05, chi-
tive consequences from untreated caries (modified square test), whereas other factors were not. For the
pufa score of ≥ 1) was 3.3%. The mean (SD) modified FIS, child’s sex was associated with the family impact
pufa was 0.1 (0.5), with range 0–7. Most (86%) of (P = 0.049, chi-square test). Table 5 shows the
the respondents were mothers. Just under half of the results of the final logistic regression model of signifi-
mothers (44.3%) and the fathers (43.4%) had cant factors associated with an ECOHIS of >0 in the
attained a secondary education. CIS, FIS and the overall (child and family) sections.
The frequency of ECOHIS responses is shown in After adjusting for the father’s and mother’s educa-
Table 2. In the child section, the most frequently tional attainment, relationship of respondent to a
reported items were ‘difficulty pronouncing any child, child’s sex and age, and consequences of
words’ (51.2%) and ‘had difficulty eating some foods’ untreated dental caries (modified pufa), caries experi-
(44.0%). Parental distress, including ‘been upset’ ence (dmft score) was the only significant variable
(46.5%) and ‘felt guilty’ (41.1%), were the most com- affecting OHRQoL of children and families (overall
monly reported items in the family section. Overall, in ECOHIS score > 0) (OR = 1.20, 95% CI: 1.07–1.35,
the present study the ECOHIS scores ranged from 0 P = 0.002). The results of the Hosmer and Lemeshow
to 39, and 235 (70.2%) parents/caregivers reported test (P = 0.732) implied goodness of fit with a
an impact on OHRQoL (ECOHIS score > 0) for at P > 0.05. For the FIS, parents having a son were 1.63
least one ECOHIS item. However, the magnitude of times more likely to have a higher negative impact on
impacts was low, with the mean (SD) score being 5.8 their OHRQoL, compared with parents who had a
(6.2) out of 52. The mean (SD) ECOHIS scores in the daughter (95% CI: 1.04–2.56, P = 0.032). When
child and family sections were 3.8 (4.3) and 2.0 (2.6), using caries experience as a categorical variable (yes/
respectively. The responses to each ECOHIS item for no) instead of a continuous variable (dmft score),

Table 2 Responses to the Chinese Early Childhood Oral Health Impact Scale (ECOHIS) items (n = 336)
Impact ECOHIS response, n (%) Mean (SD)

Never Hardly ever Occasionally Often Very often

Child impact section

How often has your child . . .. . . because of dental problems or the need for dental treatments?
Child symptom
a) Had pain in the teeth, mouth or jaws? 201 (59.8) 102 (30.4) 28 (8.3) 4 (1.2) 1 (0.3) 0.5 (0.7)
Child function
b) Had difficulty drinking beverages? 211 (62.8) 107 (31.8) 16 (4.8) 2 (0.6) 0 (0) 0.4 (0.6)
c) Had difficulty eating some foods? 188 (56.0) 103 (30.7) 37 (11.0) 6 (1.8) 2 (0.6) 0.6 (0.8)
d) Had difficulty pronouncing words? 164 (48.8) 93 (27.7) 66 (19.6) 9 (2.7) 4 (1.2) 0.8 (0.9)
e) Missed preschool, day care? 274 (81.5) 59 (17.6) 2 (0.6) 1 (0.3) 0 (0) 0.2 (0.4)
Child psychology
f) Had trouble sleeping? 250 (74.4) 71 (21.1) 12 (3.6) 2 (0.6) 1 (0.3) 0.3 (0.6)
g) Been irritable or frustrated? 216 (64.3) 97 (28.9) 19 (5.7) 2 (0.6) 2 (0.6) 0.4 (0.7)
Self-image and social interaction
h) Avoided smiling or laughing? 259 (77.1) 69 (20.5) 7 (2.1) 1 (0.3) 0 (0) 0.3 (0.5)
i) Avoided talking with other children? 260 (77.4) 72 (21.4) 3 (0.9) 1 (0.3) 0 (0) 0.2 (0.5)
Family impact section
How often have you or another family member because of your child’s dental problems or treatment?
Parental distress
j) Been upset? 183 (54.5) 105 (31.3) 39 (11.6) 8 (2.4) 1 (0.3) 0.6 (0.8)
k) Felt guilty? 198 (58.9) 89 (26.5) 38 (11.3) 7 (2.1) 4 (1.2) 0.6 (0.9)
Family function
l) Had to take hours or days off work? 239 (71.1) 81 (24.1) 12 (3.6) 3 (0.9) 1 (0.3) 0.4 (0.6)
m) Had the family’s economic situation affected? 234 (69.6) 83 (24.7) 15 (4.5) 3 (0.9) 1 (0.3) 0.4 (0.6)

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Duangthip et al.

Table 3 Responses to the Chinese Early Childhood Oral Health Impact Scale (ECOHIS) responses from children
with (n = 124) and children without (n = 212) caries experience
Impact ECOHIS response, n (%) Mean (SD)

Never Hardly ever Occasionally Often Very often

Children with caries experience (n = 124)

Child impact section
Child Symptom
a) Had pain in the teeth, mouth or jaws? 59 (47.6) 44 (35.5) 16 (12.9) 4 (3.2) 1 (0.8) 0.7 (0.9)
Child function
b) Had difficulty drinking beverages? 65 (52.4) 46 (37.1) 12 (9.7) 1 (0.8) 0 (0) 0.6 (0.7)
c) Had difficulty eating some foods? 58 (46.8) 47 (37.9) 17 (13.7) 2 (1.6) 0 (0) 0.7 (0.8)
d) Had difficulty pronouncing words? 57 (46) 39 (31.5) 24 (19.4) 3 (2.4) 1 (0.8) 0.8 (0.9)
e) Missed preschool, day care? 92 (74.2) 29 (23.4) 2 (1.6) 1 (0.8) 0 (0) 0.3 (0.5)
Child psychology
f) Had trouble sleeping? 81 (65.3) 38 (30.6) 4 (3.2) 1 (0.8) 0 (0) 0.4 (0.6)
g) Been irritable or frustrated? 74 (59.7) 45 (36.3) 4 (3.2) 1 (0.8) 0 (0) 0.5 (0.6)
Self-image and social interaction
h) Avoided smiling or laughing? 86 (69.4) 34 (27.4) 3 (2.4) 1 (0.8) 0 (0) 0.4 (0.6)
i) Avoided talking with other children? 88 (71) 34 (27.4) 1 (0.8) 1 (0.8) 0 (0) 0.3 (0.5)
Family impact section
Parental distress
j) Been upset? 56 (45.2) 42 (33.9) 18 (14.5) 7 (5.6) 1 (0.8) 0.8 (0.9)
k) Felt guilty? 54 (43.5) 43 (34.7) 19 (15.3) 5 (4) 3 (2.4) 0.9 (1.0)
Family function
l) Had to take hours or days off work? 73 (58.9) 40 (32.3) 8 (6.5) 2 (1.6) 1 (0.8) 0.5 (0.8)
m) Affected family’s economic situation? 73 (58.9) 40 (32.3) 8 (6.5) 2 (1.6) 1 (0.8) 0.5 (0.8)
Children without caries experience (n = 212)
Child impact section
Child symptom
a) Had pain in the teeth, mouth or jaws? 142 (67) 58 (27.4) 12 (5.7) 0 (0) 0 (0) 0.4 (0.6)
Child Function
b) Had difficulty drinking beverages? 146 (68.9) 61 (28.8) 4 (1.9) 1 (0.5) 0 (0) 0.3 (0.5)
c) Had difficulty eating some foods? 130 (61.3) 56 (26.4) 20 (9.4) 4 (1.9) 2 (0.9) 0.6 (0.8)
d) Had difficulty pronouncing words? 107 (50.5) 54 (25.5) 42 (19.8) 6 (2.8) 3 (1.4) 0.8 (1.0)
e) Missed preschool, day care? 182 (85.8) 30 (14.2) 0 (0) 0 (0) 0 (0) 0.1 (0.3)
Child psychology
f) Had trouble sleeping? 169 (79.7) 33 (15.6) 8 (3.8) 1 (0.5) 1 (0.5) 0.3 (0.6)
g) Been irritable or frustrated? 142 (67) 52 (24.5) 15 (7.1) 1 (0.5) 2 (0.9) 0.4 (0.7)
Self-image and social interaction
h) Avoided smiling or laughing? 173 (81.6) 35 (16.5) 4 (1.9) 0 (0) 0 (0) 0.2 (0.4)
i) Avoided talking with other children? 172 (81.1) 38 (17.9) 2 (0.9) 0 (0) 0 (0) 0.2 (0.4)
Family impact section
Parental distress
j) Been upset? 127 (59.9) 63 (29.7) 21 (9.9) 1 (0.5) 0 (0) 0.5 (0.7)
k) Felt guilty? 144 (67.9) 46 (21.7) 19 (9) 2 (0.9) 1 (0.5) 0.4 (0.7)
Family function
l) Had to take hours or days off work? 166 (78.3) 41 (19.3) 4 (1.9) 1 (0.5) 0 (0) 0.3 (0.5)
m) Affected family’s economic situation? 161 (75.9) 43 (20.3) 7 (3.3) 1 (0.5) 0 (0) 0.3 (0.5)

caries experience was 2.02 times as likely to have a study compared with a previous population-based sur-
negative impact on a child’s OHRQoL compared with vey13. This may be because the children in the present
no caries experience (95% CI: 1.20–3.39, P = 0.008). study were older than those in the previous study
(4.7 years vs. 3.9 years) and had higher caries preva-
lence (36.9% vs. 19.9%)13.
DISCUSSION
Regarding the association between OHRQoL and
Quality of life has important implications for health dental caries, the chances of having negative impacts
research and practice10. Subjective oral health status were observed among children with higher caries
should be considered when assessing oral health status experience. For every one unit increase in dmft score,
and perceived needs in a community8. The results of the chance of having an impact on a child’s OHRQoL
the present study indicate that although the overall was 1.2 times as likely. This is in agreement with the
impact of oral health was not high (scoring 5 out of results of studies conducted in diverse geographical
52), the majority (70%) of the parents reported an areas such as Brazil17, France18 and Trinidad14. The
adverse effect on OHRQoL (ECOHIS score of > 0) caries status of Hong Kong preschool children has not
for at least one item. Parents reported a slightly higher been improved in the last decade. No third-party pay-
adverse effect of caries on OHRoL in the current ment coverage or government-subsidised dental care
104 © 2019 FDI World Dental Federation
 Oral health-related quality of life of children

Table 4 Bivariate analysis of various factors related to the Chinese Early Childhood Oral Health Impact Scale
Variable % of child impacts % of family impacts % of overall impact
(CIS score > 0) (FIS score > 0) (ECOHIS > 0)

Parent demographics
Relationship to the child
Mother 64.0% (185/289) 48.1% (139/289) 70.2% (203/289)
Other family member 66.0% (31/47) 46.8% (22/47) 70.2% (33/47)
Mother’s education level
Lower secondary school or lower 60.2% (53/88) 50.0% (44/88) 65.9% (58/88)
Secondary school 71.1% (106/149) 47.0% (70/149) 75.2% (112/149)
Post-secondary school/University 57.6% (57/99) 47.5% (47/99) 66.7% (66/99)
Father’s education level
Lower secondary school or lower 64.0% (57/89) 47.2% (42/89) 68.5% (61/89)
Secondary school 65.8% (96/146) 48.6% (71/146) 70.5% (103/146)
Post-secondary school/University 62.4% (63/101) 47.5% (48/101) 71.3% (72/101)
Child demographics and caries status
Sex *
Male 67.5% (114/169) 53.3% (90/169) 73.4% (124/169)
Female 61.1% (102/167) 42.5% (71/167) 67.1% (112/167)
Age (years)
4 68.2% (180/264) 62.9% (166/264) 46.2% (122/264)
5 77.8% (56/72) 69.4% (50/72) 54.2% (39/72)
Decayed teeth (dt) * ** **
dt = 0 59.6% (127/213) 40.8% (87/213) 65.3% (139/213)
dt ≥ 1 72.4% (89/123) 60.2% (74/123) 78.9% (97/123)
Missing teeth (mt)
mt = 0 64.3% (216/336) 47.9% (161/336) 70.2% (236/336)
mt > 1 NA NA NA
Filled teeth (ft)
ft = 0 64.4% (208/323) 47.1% (152/323) 70.3% (227/323)
ft ≥ 1 61.5% (8/13) 69.2% (9/13) 69.2% (9/13)
Decayed, missing or filled teeth (dmft) * *** **
dmft = 0 59.9% (127/212) 40.6% (86/212) 65.1% (138/212)
dmft ≥ 1 71.8% (89/124) 60.5% (75/124) 79% (98/124)
Modified pufa
Modified pufa = 0 69.5% (226/325) 63.4% (206/325) 47.4% (154/325)
Modified pufa ≥ 1 90.9% (10/11) 90.9% (10/11) 63.6% (7/11)

CIS, child impact section; FIS, family impact section; NA, not applicable; pufa, oral conditions of untreated caries.
Chi-square test, *P < 0.05, **P < 0.01, ***P < 0.001.

services exist for preschool children in Hong Kong19. therapy, may be beneficial in preventing and control-
Our results corroborate the evidence that untreated ling disease progression22. Although no missing teeth
caries has ramifications not just for oral health but due to caries (mt) were recorded, difficulty pronounc-
also for the general health of the affected chil- ing any words was the prevalent OHRQoL impact
dren20,21. The burden of ECC and its impacts beyond rated by parents. Possibly, this may be related to non-
the clinical aspects suggest the need to address specific caries-related factors, such as malocclusion or previ-
strategies to improve dental health in childhood. ous traumatic dental injury. Although the results of
Effective evidence-based approaches, including a the Hosmer–Lemeshow test implied goodness of fit
supervised toothbrushing program with fluoridated with P > 0.05, the association of other unmeasured
toothpaste and topical fluoride treatment in a school oral conditions with an impact on OHRQoL should
setting, should be established to improve the oral be further explored. In the family section, guilty and
health of Hong Kong preschool children5. upset feeling by the parents were the most frequently
In the current study, the most frequently reported reported impacts, which were similar to the results of
domains were symptoms and functional limitations, previous studies18,20. Within the same ethnic group,
whereas the domains of child self-image and social Chinese parents in Hong Kong had higher distress
interaction were reported least frequently. These than those in Mainland China, although the status of
results are consistent with those in previous stud- their children’s caries was similar23. The discrepancy
ies17,18. Thus, pain relief and functional improvement in parental responses may be a result of the different
should be primary treatment goals for managing tooth social and economic development in these two areas.
decay in young children. In the current situation Socio-economic status has been found to be one of
where most cavities are untreated, simple and cost-ef- the risk factors associated with dental caries24. In
fective approaches, such as silver diamine fluoride addition, children from low social classes had worse
© 2019 FDI World Dental Federation 105
Duangthip et al.

Table 5 Final model of logistic regression of ECOHIS method. Moreover, the caries prevalence (36.9%) of
the study children aged 4 years was lower than that
Odds ratio 95% CI P value
(43.1%) of the same age group in a recent territory-
Model A: Caries experience(dmft score) and modified pufa - wide oral health survey29. However, parental educa-
continuous variables
Child impacts†
tional attainment in the present study was similar to
dmft score 1.18 1.07–1.31 0.001 that of the Hong Kong population overall regarding
Family impacts‡ attainment of secondary (47.3%) and higher (32.7%)
dmft score 1.23 1.12–1.35 <0.001
Child’s sex 0.032
education levels30. As a result of the sampling bias
Female* from non-probability sampling, we cautiously make
Male 1.63 1.04–2.56 inferences from these study samples to the general pop-
Overall (Child+Parent) impacts†
dmft score 1.20 1.07–1.35 0.002
ulation. In addition, this was a cross-sectional study;
Model B: Caries experience and modified pufa (yes/no)-categorical the exposure (dental caries), outcome (ECOHIS) and
variables other confounding factors were simultaneously evalu-
Child impacts†
Caries experience (yes/no*) 1.70 1.06–2.75 0.029
ated. Thus, there is no evidence regarding a temporal
Family impacts‡ relationship between dental caries and OHRQoL.
Caries experience (yes/no*) 2.30 1.46–3.63 <0.001 Recall bias also possibly influenced the caregivers’
Child’s sex
Female*
responses. The adoption of parent proxy may not be
Male 1.61 1.03–2.50 0.035 ideal, but it is satisfactory and reasonable given the lin-
Overall (Child+Parent) impacts† guistic and cognitive aspects of early childhood31. A
Caries experience (yes/no*) 2.02 1.21–3.39 0.008
well-designed prospective study using representative
*Reference group; CI, confidence interval. samples is required to provide more information
†
Excluded variables: relationship of respondent to a child, education regarding the causal effect of dental caries on OHR-
level of mother and father, child’s sex and age, modified pufa.
‡
Excluded variables: relationship of respondent to the child, educa- QoL of the affected children and their families.
tion level of mother and father, child’s age, modified pufa. Dental caries in primary teeth may be a potential
health problem, with repercussions extending beyond
its clinical signs and symptoms. An increase of more
OHRQoL after adjustment for potentially confound- than one decayed primary tooth has a significantly neg-
ing factors25. Conflicting findings were published26. In ative impact on the OHRQoL of the affected children
the present study, no association between socio-eco- and families. However, the magnitude of the perceived
nomic status and OHRQoL was observed. Although impact on OHRQoL was low in Hong Kong. Atten-
mothers and fathers were allowed to be proxies in the tion should be paid, at a broader policy level, to
present study, most (86%) were mothers. The depth increase knowledge and awareness as well as to
of awareness and agreement in child’s oral health improve access to oral care for preschool children, thus
between proxies may be different. Following the improving the quality of life of preschool children.
results of multivariate logistic regression analysis, rela- In summary, caries experience of preschool children
tionship of respondent to child (either mother or is significantly associated with negative family and
others) had no effect on child’s OHRQoL. Interest- child experiences, contributing to a lower OHRQoL,
ingly, association between the child’s gender and par- regardless of their socio-economic status.
ental distress was observed. Parents having a boy had
higher negative family impacts than those having a
Acknowledgements
girl, even after adjustment. This may be due to the
patrilineal culture. Gender values in Chinese sociocul- The authors thank Ms Samantha K, Y Li for her assis-
tural contexts were associated with the functionality tance with statistical analysis. This study did not
of family in several aspects, including child-rearing27. receive any financial support from funding agencies.
This may lead to higher parental expectation and
social pressure when parenting a boy. The parent–
Conflict of interests
child relationship is complex and individualised28.
Social and behavioural factors influencing child oral All authors declare no conflict of interest.
health should be further studied.
The strengths of this study include the use of a vali-
REFERENCES
dated OHRQoL measure, good intra-examiner reliabil-
ity of the dental examination, acceptable participation 1. American Academy of Pediatric Dentistry. Policy on early child-
hood caries (ECC): classifications, consequences, and preventive
rates and sufficient sample size. Several study limita- strategies. Pediatr Dent 2016 38: 52–54.
tions should be addressed. The reliability of the par- 2. GBD 2015 Disease and Injury Incidence and Prevalence Collab-
ents’ answers was not assessed. In addition, the study orators. Global, regional, and national incidence, prevalence,
children were selected using a non-probability sampling and years lived with disability for 310 diseases and injuries,

106 © 2019 FDI World Dental Federation

 Oral health-related quality of life of children

1990-2015: a systematic analysis for the Global Burden of Dis- 20. Sheiham A. Dental caries affects body weight, growth and
ease Study 2015. Lancet 2016 388:1545–1602. quality of life in pre-school children. Br Dent J 2006 201:
3. Chen KJ, Gao SS, Duangthip D et al. Dental caries status and 625–626.
its associated factors among 5-year-old Hong Kong children: a 21. Correa-Faria P, Daher A, Freire M et al. Impact of untreated
cross-sectional study. BMC Oral Health 2017 17: 121. dental caries severity on the quality of life of preschool children
4. Chu CH, Fung DS, Lo ECM. Dental caries status of preschool and their families: a cross-sectional study. Qual Life Res 2018
children in Hong Kong. Br Dent J 1999 187: 616–620. 27: 3191–3198.
5. Chen KJ, Gao SS, Duangthip D et al. Early childhood caries 22. Duangthip D, Chen KJ, Gao SS et al. Managing early child-
and oral health care of Hong Kong preschool children. Clin hood caries with atraumatic restorative treatment and topical
Cosmet Investig Dent 2019 11: 27–35. silver and fluoride agents. Int J Environ Res Public Health
2017 14: 1204.
6. Casamassimo PS, Thikkurissy S, Edelstein BL et al. Beyond the
dmft: the human and economic cost of early childhood caries. J 23. Li MY, Zhi QH, Zhou Y et al. Impact of early childhood car-
Am Dent Assoc 2009 140: 650–657. ies on oral health-related quality of life of preschool children.
Eur J Paediatr Dent 2015 16: 65–72.
7. World Health Organization, Constitution of WHO: principles.
Available from: https://www.who.int/about/mission/en/. Accessed 24. Schwendicke F, Dorfer CE, Schlattmann P et al. Socioeconomic
15 October 2018. inequality and caries: a systematic review and meta-analysis. J
Dent Res 2015 94: 10–18.
8. Allen PF. Assessment of oral health related quality of life.
Health Qual Life Outcomes 2003 1: 40. 25. Piovesan C, Antunes JL, Guedes RS et al. Impact of socioe-
conomic and clinical factors on child oral health-related
9. Locker D, Allen F. What do measures of ‘oral health-related quality of life (COHRQoL). Qual Life Res 2010 19: 1359–
quality of life’ measure? Community Dent Oral Epidemiol 1366.
2007 35: 401–411.
26. Kumar S, Kroon J, Lalloo R. A systematic review of the impact
10. Sischo L, Broder HL. Oral health-related quality of life: what, of parental socio-economic status and home environment char-
why, how, and future implications. J Dent Res 2011 90: 1264– acteristics on children’s oral health related quality of life.
1270. Health Qual Life Outcomes 2014 12: 41.
11. Pahel BT, Rozier RG, Slade GD. Parental perceptions of chil- 27. Hu Y, Scott J. Family and gender values in China: generational,
dren’s oral health: the Early Childhood Oral Health Impact geographic, and gender differences. J Fam Issues 2014 37:
Scale (ECOHIS). Health Qual Life Outcomes 2007 5: 6. 1267–1293.
12. Lee GH, McGrath CP, Yiu CK et al. Translation and valida- 28. Lutz KF, Anderson LS, Riesch SK et al. Furthering the under-
tion of a Chinese language version of the Early Childhood Oral standing of parent-child relationships: a nursing scholarship
Health Impact Scale (ECOHIS). Int J Paediatr Dent 2009 19: review series. Part 2: grasping the early parenting experience-
399–405. the insider view. J Spec Pediatr Nurs 2009 14: 262–283.
13. Wong HM, McGrath CP, King NM et al. Oral health-related 29. Duangthip D, Chen KJ, Gao SS et al. Early childhood caries
quality of life in Hong Kong preschool children. Caries Res among 3- to 5-year-old children in Hong Kong. Int Dent J
2011 45: 370–376. 2019 69: 230–236.
14. Naidu R, Nunn J, Donnelly-Swift E. Oral health-related quality 30. Census and Statistics Department, the Government of Hong
of life and early childhood caries among preschool children in Kong Special Administrative Region. Population in Census.;
Trinidad. BMC Oral Health 2016 16: 128. 2016. Available from https://www.bycensus2016.gov.hk/da
15. World Health Organization. Oral health surveys-basic methods. ta/snapshotPDF/Snapshot02.pdf. Accessed date 16 May
Available from: http://apps.who.int/iris/bitstream/10665/97035/ 2019.
1/9789241548649_eng.pdf?ua=1. Assessed 25 October 2018. 31. Wilson-Genderson M, Broder HL, Phillips C. Concordance
16. Figueiredo MJ, de Amorim RG, Leal SC et al. Prevalence and between caregiver and child reports of children’s oral health-re-
severity of clinical consequences of untreated dentine carious lated quality of life. Community Dent Oral Epidemiol 2007
lesions in children from a deprived area of Brazil. Caries Res 35: 32–40.
2011 45: 435–442.
17. Antunes LAA, Ornellas G, Fraga RS et al. Oral health out- Correspondence to:
comes: the association of clinical and socio-dental indicators to Duangporn Duangthip,
evaluate dental caries in preschool children. Cien Saude Colet
2018 23: 491–500. Faculty of Dentistry,
18. Li S, Veronneau J, Allison PJ. Validation of a French language The University of Hong Kong,
version of the Early Childhood Oral Health Impact Scale Prince Philip Dental Hospital,
(ECOHIS). Health Qual Life Outcomes 2008 6: 9. Hong Kong, China.
19. Gao SS, Chen KJ, Duangthip D et al. Oral health care in Hong Email: dduang@hku.hk
Kong. Healthcare (Basel) 2018 6: 45.
http://facdent.hku.hk

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