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Pediatr Dent. Author manuscript; available in PMC 2010 September 15.
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Pediatr Dent. 2010 ; 32(1): 4855.
Behavioral Determinants of Brushing Young Children's Teeth:

Implications for Anticipatory Guidance
Colleen E. Huebner, PhD, MPH1 and Christine A. Riedy, PhD, MPH2

1Dr. Huebner is associate professor of Health Services and is adjunct associate professor of
Pediatric Dentistry and of Family and Child Nursing

2Dr.Riedy is research associate professor of Dental Public Health Sciences and is adjunct research
associate professor of Health Services, both at the University of Washington, Seattle, Wash
Abstract
PurposeThe purposes of this study were to identify parents' motivation, support, and barriers to
twice daily tooth-brushing of infants and preschool-age children and to discover new approaches to
encourage this important health behavior.
MethodsQualitative interviews were conducted with 44 rural parents about tooth-brushing habits
and experiences.
ResultsForty of 44 parents reported that they had begun to brush their child's teeth; 24 (55%)
reported brushing twice a day or more. Parents who brushed twice a day, vs less often, were more
likely to describe specific skills to overcome barriers; they expressed high self-efficacy and held high
self-standards for brushing. Parents who brushed their children's teeth less than twice daily were
more likely to: hold false beliefs about the benefits of twice daily tooth-brushing; report little
normative pressure or social support for the behavior; have lower self-standards; describe more
external constraints; and offer fewer ideas to overcome barriers.
ConclusionsThe findings support an integrative framework in which barriers and support for
parents' twice daily brushing of their young children's teeth are multiple and vary among individuals.
Knowledge of behavioral determinants specific to individual parents could strengthen anticipatory
guidance and recommendations about at-home oral hygiene of young children.
Keywords
Health Promotion; Health Services; Access to Care; Infant Oral Health; Early Childhood Caries;
Oral Habits; Preventive Dentistry
Recent policy statements and clinical guidelines of the American Academy of Pediatric
Dentistry (AAPD) emphasize the Academy's support of the concept of a dental home for
infants, children, and adolescents. The American Academy of Pediatrics' (AAP) policy on the
dental home, published in 2003,1 encourages parents and other caregivers to establish a source
of professional dental care for their children by 12- months of age. This position was elaborated
in 2008 in a joint statement by the AAPD and AAP that recommends establishing a dental
home within 6 months of eruption of the first tooth and no later than 12-months-old.2 As this
policy is implemented and reinforced by other health care professionals, it will change the
patient mix seen by many dental providers and expand the content of care for infants and young
children. Currently, relatively few children see a dentist prior 3-years-old. The National Survey
Correspond with Dr. Huebner at colleenh@u.washington.edu.

Huebner and Riedy Page 2
of Children's Health, a telephone survey conducted on over 100,000 US parents of children

from infancy to 17-years-old, found that only 24% of 2-year-olds received a preventive dental
visit in the previous year. This was true of just 10% of 1-year-old children.3
Dentists can play an important role in the primary prevention of dental problems in young
children through preventive treatments, risk assessment, and anticipatory guidance for parents
regarding oral development, caries prevention, and overall oral health.4 Recommendations for
at-home preventive measures, including brushing infants' and young children's teeth and using
fluoride toothpaste, are key elements of anticipatory guidance to be provided to parents by the
child's dental home.2 Perhaps surprisingly, relatively few parents meet professionals'
recommendations to brush their children's teeth twice a day. A recent international study
involving parents of over 2,800 children (4-years-old on average) documented wide variation
in the frequency of parent-child tooth-brushing both between countries and between racial/
ethnic groups. Within the US groups, twice daily tooth-brushing ranged from a high of 64%
for African American children to a low of 50% for Caucasian children. Overall, the brushing
behavior most strongly associated with being caries free at 4-years-old was onset of tooth-
brushing prior to 2-years-old. This study made an important discovery: The single best
predictor of children being caries-free was not a behavior at all, but a parents' belief that they
could carry out regular tooth-brushing.5,6 Research by Blinkhorn et al. supports the point that
effective tooth-brushing requires something more than simply knowing it is important. Their
study, of 268 mothers, included questions about oral hygiene and direct observation of mothers
brushing their preschool children's teeth. They reported that most mothers (71%) knew they
should brush twice daily, but only half knew they should use a small amount of toothpaste and
less than half (40%) showed adequate tooth-brushing skills.7 A study of 1,021 inner city
African American mothers of 1- to 5-year-olds had similar findings.8 In this study, parents
reported brushing their children's teeth approximately 9 times per week on average, which is
below the recommended frequency of twice daily (14 times per week).
Additional research is needed to identify what parents know and need to protect their young
children's dental health by brushing regularly. Information about why people do what they do
the determinants of behavioris essential to design effective health promotion programs.
Fishbein and colleagues9,10 have proposed an integrative model of health behavior that draws
together several prominent theories of behavior performance and behavior change, including
aspects of the theory of health belief, social cognitive theory, theory of reasoned action, and
theory of planned behavior. The model posits intention as the primary determinant of behavior.
Intention is described as a subjective probability that varies on a continuum from no or low
likelihood to strong likelihood of performing a given behavior. Intention is a consequence of
behavioral beliefs that give rise to proximate influences, including social norms and
individuals' self-efficacy.
An individual's intention to perform a behavior can be impeded, however, by external

constraints or an individual's lack of skills. The model predicts that a strong intention, the
necessary skills, and lack of constraints are necessary and sufficient conditions for behavioral
performance. Thus, individual differences in intention and associated beliefs, skills, and
external constraints could explain why programs designed to increase tooth-brushing
frequency are effective with some, but not all, parents of young children.11
The role of behavioral beliefs and related norms, self-standards, and self-efficacy has been
largely untapped by studies of tooth-brushing behavior. These factors can vary among
individuals by population subgroups or culture.12 Community characteristics also can define
subgroups. Compared with their urban counterparts, poor rural parents are more likely to be
younger and geographically isolated.13 Consequently, young rural parents might be less
knowledgeable about where to turn for oral health advice or services. Additionally, in many

rural communities there is a high value placed on self-reliance and strong social stigma
associated with participating in public assistance programs.13
Thus, even if parents are aware of and have access to resources for their children, rural parents
might avoid using them, preferring to get by on their own or with the help of family members.
Utilization data show that rural vs nonrural children are less likely to use dental services overall
and that rural parents are more likely to report the purpose of the last dental visit was due to
something bothering or hurting their children.14 For all these reasonsisolation, parents'
young age, limited formal education or knowledge of children's oral health needs, and a value
of self-reliancerural children especially might benefit from simple interventions to
encourage an early and regular habit of parent-child tooth-brushing.
The goal of the present study was to identify motivation, barriers, and support for twice daily
tooth-brushing by parents of infants and preschool-age children. The study was designed to
answer 3 specific questions:
1. What are the home oral hygiene practices of low-income rural parents of young
children?
2. Do determinants of behavior, described by the integrative model, distinguish parents
who brush their young children's teeth twice daily from parents who brush less often?
3. Based on parents' personal experiences and reflections, what could support an early
habit of twice daily parent-child tooth-brushing?

The results will be used to advance the prevention focus, emphasized in the Surgeon General's
report, Oral Health in America, that safe and effective disease prevention measures exist that
everyone can adopt to improve oral health and disease prevention15 by identifying information
about parent-child tooth-brushing that can be used to tailor anticipatory guidance for parents
and augment community-based oral health promotion efforts.
Methods
Setting and sample
The setting was a rural county located in the southwestern region of Washington State. At the
time of the study in 2006 and 2007, the population was approximately 15,000 people; most
were Caucasian and spoke English as their primary language (95%). Nearly 1 in 5 (19%)
children lived in families with household incomes below the federal poverty level. One quarter
of adults who were at least 25-years-old lacked a high school diploma. Parents who participated
in the research were clients of 1 of 3 early childhood education programs in the community
that served low-income families with infants or preschoolers. The reason for the restriction
was to elicit information that could be used in future parental education programs.
Design
We used a community-based participatory research approach to include parents and
community-based health professionals in each step of the study design and data collection. The
chosen method was one-to-one qualitative interviews with parents of infants and preschoolers.
Parents were invited to participate in the research process as expert informants to help
researchers create information for parents of young children about how to take good care of
their child's teeth. Our goal was to elucidate a diverse set of points of view regarding the value
and ease of brushing young children's teeth rather than to obtain a statistically representative
community sample. We expected that 40 to 45 interviews would be needed before we could

identify patterns in parents' responses, by which time additional interviews would provide no
new information.
Study protocols and the interview guide were reviewed, revised, and approved by a steering
committee coordinated by the study investigator. The committee consisted of 7 community
residents, including 5 professionals in early childhood health or education and 2 low-income
mothers with young children. Parent members were paid a stipend of $50 for 6 months service
on the committee. The committee focused primarily on the appropriateness of the wording of
each question, especially for parents with limited education and single parents who might be
offended by questions that assumed a traditional family structure. The interviews were
conducted by 3 paid community residents trained by the study investigators and who, prior to
data collection, completed training in conducting research on human subjects. All procedures
were approved by the Institutional Review Board of the University of Washington, Seattle,
Wash. Informed written consent was obtained just prior to the actual interviews.
Measures
InterviewsThe final version of the interview guide included 9 open-ended questions about
when, or if, parents had begun brushing their child's teeth, why they began, how often they
were brushing currently, and barriers and sources of support for twice daily tooth-brushing.
To measure a parent's intentions toward tooth-brushing, we asked on a scale of 1 to 10 how
confident are you that you will start, or continue, brushing your child's teeth twice a day?
The interviews were audio recorded and transcribed by an individual unaffiliated with the
study. The transcripts were compared to the audio-recordings to ensure accuracy and then
coded by the study investigators. The coding used a mixed-method, qualitative approach.16
Techniques of grounded theory, specifically the iterative process of open coding and grouping
similar codes, were used to extract all information about supports and barriers to brushing a
child's teeth and identify core concepts. As those concepts emerged, we mapped them to the
determinants of behavior described by the integrative model9: intention; behavioral beliefs (ie,
norms, emotional reactions, self-standards, self-efficacy); skills; and external constraints. Our
plan was to capture both positive and negative influences on the initiation of gum or tooth
cleaning and on current tooth-brushing behavior.
Results
Participants included 44 mothers and 1 father; interviews lasted less than 30 minutes in length.
Fourteen of the 44 parents (32%) were younger than 21-years-old. Twenty-seven parents (61%)
had a child younger than 3-years-old; the remainder included parents whose youngest child
was up to 5-years-old. Twenty-eight of the 44 parents (64%) were first-time parents. Twenty-
seven of the 44 children described in the study were boys.
Initiation and frequency of parent-child tooth-brushing

Three parents did not report the age at which they began brushing their children's teeth. Of the
41 parents who did discuss this, 26 (63%) reported that they began brushing their child's teeth
before their child's first birthday. Nine began brushing when their child was 1-year-old, and 2
began when their child was at least 2-years-old. Four parents (of 1- to 5-year-olds) had not yet
begun brushing. Fewer than half (48%) of all 44 parents reported that anyone had ever shown
them how to brush a young child's teeth. For most, this was a parenting skill they worked out
on their own. Several recalled reluctance and fear that they lacked the skill needed to brush
without hurting their baby's mouth.

When asked why they began brushing their children's teeth, parents' discussed 1 or more of 7
determinants anticipated by the integrative model. The 3 most common, in rank order, pertained
to: (1) oral health beliefs (discussed by 10 parents); (2) social norms (7 parents); and (3) external
factors (7 parents). Table 1 presents an example given by a parent for each of the 7 determinants.
An unexpected finding was one illustration of the influence of social norms on the initiation
of brushing in this case, the young child noticed other family members brushing their teeth
and wanted to join in.
When asked if twice daily brushing was a very realistic recommendation for parents, 40 of
44 parents said it was realistic, yet only 22 reported achieving this goal. Of the total sample, 4
had not yet begun tooth-brushing, 1 reported doing so on average less than once a day, 15
reported brushing once a day, and 24 of 44 (55%) reported brushing two or more times a day.
Twice daily brushing was most often described in terms of a morning and bedtime or evening
routine. Among parents who reported brushing less than twice a day, morning brushing was
most often skipped due to early and inflexible work or school schedules. Some parents reported
that it was easier to achieve twice-a-day brushing on the weekends.
A child's age was not related to brushing frequency (Table 2). Five of 6 parents (83%) with
children 1-year-old and younger reported brushing twice a day. Brushing at least twice a day
was reported by 5 of 12 parents (42%) with 1- to 2-year-olds, and by 14 of 26 parents (54%)
with children who were at least 2-years-old. Brushing frequency was strongly associated with
parents' self-report of their confidence to continue or begin this health behavior. For the group
as a whole, the average confidence rating for brushing at least twice a day was 8.5 on a scale
of 1 (low) to 10 (high); the range was from 3 to 10 points. The average confidence rating of
parents who reported achieving this goal was 9.4 (mean=9.380.92 SD); the average of those
who reported less frequent brushing was 7.5 (mean=7.501.99). A test of the difference
between the means was statistically significant (t [43]=3.89; P<.00l).
Who does the brushing?

When describing a typical tooth-brushing session, 11 of the 40 (28%) parents who were
brushing said they brushed their child's teeth for them, or went over the teeth to ensure thorough
cleaning. The most common pattern, described by 22 of 40 parents (55%), was to be physically
present and supervise the child's tooth-brushing behavior or brush their own teeth at the same
time. One parent described tooth-brushing this way: I just take him to the bathroom. I give
him the toothbrush, and he loves to brush his teeth for ever. Seven parents (18%) reported
that their child brushed on his or her own, without supervision. One explained this in terms of
logistic difficulties: It's all her. With 2 kids and even more adults in this house, it's kind of
difficult to be the one standing next to her when she is brushing. Another shared with pride,
She brushes her own teeth, and she's been doing that since she was two-and-a-half [years
old].
Determinants of current tooth-brushing

Our analysis identified 21 sources of influence on tooth-brushing frequency and how the task
was carried out (ie, who did the actual brushing). Twelve category codes described facilitators
of tooth-brushing, and 9 codes captured barriers. The concepts reflected in the codes were
consistent with the 7 behavioral determinants described by the integrative model. In our data,
examples of each determinant were offered by 1 or more parents as a source of support and by
at least 1 parent as a type of barrier. In addition to identifying positive and negative influences
on brushing, we sorted the data to learn if influences differed for those who reported brushing
their child's teeth twice or more a day from those who reported brushing less frequently. The
results, with examples drawn from the interviews, are summarized in Table 3 and discussed
below.

Facilitators
In reporting sources of support for regular brushing, we restricted our analysis to information
provided by the 40 parents who had begun brushing their children's teeth; 4 parents, not yet
brushing, were excluded.
Oral health beliefs

Most parents held the beliefs that home oral hygiene is effective and it is a parental duty to
establish this behavior with children. Origins of parents' beliefs were apparent in their
reflections on what they wanted and did not want for their children, often tied to their own
adverse experiences with dental care or having poor teeth. One parent explained, You need
to brush their teeth; that's really something you need to do for your kids so they don't have bad
teeth later in life. Another parent discussed the importance of brushing in terms of its minimal
cost and associated benefits: Because I feel like brushing your teeth is really important and,
like I said, it only takes two minutes a day vs a lot of pain in the future.
Social norms
Twenty-six of 40 parents reported having social support for regular tooth-brushing. The most
common source of support was the extended family, however one parent enlisted a celebrity
to bolster support: I got him Spider-man toothpaste. We talk about Spider-man and how he
would brush his teeth and [I] use his heroes to kinda play on to that. 'Spiderman would brush
his teeth so he doesn't get cavities' and he [son] wants to be like him, so he'll like start brushing
his teeth more, too. Siblings also were enlisted as role models for younger brothers and sisters.
Emotional reactions
Emotional reactions to the consequences of not brushing were cited by 18 parents (45%) as a
source of motivation for brushing. One parent offered: A really scary picture of horrible decay
might get me to be more regular about brushing. Another parent explained how it felt when
but I like forgot to brush, you know, like for a couple of days and you can see, you know,
you can start seeing the build-up and it's just it's not OK. It's gross.
Self-standards
Overall, 33 parents described self-standards as a source of influence. One parent said, Yeah,
I try to push for 3 [times per day], but he's 5so probably about 2 to 3 [times per day]. Some
parents recalled past childhood experiences, for instance, I grew up in a family that didn't
brush their teeth, and I am trying to do better than my parents. High self-standards as a
behavioral determinant were described by all 24 parents who reported brushing at least twice
a day and by 9 of 16 (56%) parents who had started brushing but were doing so less than twice
a day.
Self-efficacy
Seven parents (18%) said establishing tooth-brushing as a structured part of the day or just
figuring it out on their own made the experience more manageable. Not surprisingly, parents
who reported brushing at least twice a day were more likely to describe it as routine. For them,
their children came to understand that brushing was just one of several tasks of the morning
and evening. One parent explained, I mean it's something that you just have to do. It's just,
you know, part of the routine, and it's like if your kid doesn't like vegetables, you have to give
vegetables.

Skills
Fourteen parents (35%) described a variety of skills they used to encourage their children's
cooperation. The most common was to make it fun for the child. One parent followed her
dentist's lead: With my son, I have to play with him. And when we went to the dentist the first
time they were telling him to open his alligator mouth to make it a game for him, so he was!
It was fun for him and it helped him, so I have to say things like that. My older daughter does
it on her own. But my son, I have to sort of supervise him and make it a game for him. Another
parent incorporated songs into the tooth-brushing routine, Umm just making it fun, singing
songs. My daughter, she sings Happy Birthday or ABCs. Three volunteered that being
flexible about location was helpful; they described brushing in the bath, while the child watched
a video, or in car if necessary. A few parents suggested the benefits of visual reminders, such
as checklists or charts hung in plain sight, and one offered the idea of using stickers as an
incentive to encourage the child to brush.
External supports
When asked what makes brushing easier, 15 parents (38%) said it was easier if the child was
cooperative or in control. One mother explained it this way: I let her do it, really cause as
long as she is doing it herself she thinks it is a good idea, but if I was to like sit there and make
her do it, that's when she gets all fussy. Several noted that child-oriented supplies such as
cartoon-character toothbrushes and flavored toothpastes were an effective enticement. One
parent said: We just got a vibrating one [toothbrush] and he's going like, Ahh! And whenever
he sees it, Whirr.whirr whirr he says. And and then if we take it from him he gets
really mad so. He like actually really likes that kind of stuff.
Barriers
All parents (N=44) were included in the analysis of barriers to tooth-brushing.
Oral health beliefs

Seven parents (16%) shared beliefs about tooth-brushing when discussing obstacles to
brushing. Some were false beliefs. For example, one parent remarked, People say that if you
like brush more than you're supposed to it picks off the enamel or something. Beliefs as
barriers were described by 5 parents (25%) who brushed less than twice a day and 2 parents
(8%) who reported brushing twice a day or more.
Social norms
Sixteen parents (36%) said the lack of a social norm or other support for twice daily brushing
made it more difficult to achieve. One mother summed it up this way: It's just coming down
to basically her and I.
Emotional reactions
Emotional reactions were apparent in the descriptions of parent-child tooth-brushing given by
5 parents. They talked about not wanting to upset their child, and in turn, themselves. One said,
It's kind of distressing him being so resistant. Another parent described how her child's
emotional reaction prevented or curtailed brushing. She said, Yeah, 'cause I wouldn't want
him to get that upset and be scared to brush his teeth later on. Honestly.
Self-standards
Eleven parents (25%) held relatively low self-standards for brushing; most (9 of 11) were
brushing less than twice a day and some felt that brushing once a day was sufficient. For

example, one parent reported, If I get them once before bed, I think it's better than forgetting.
Another labeled herself as just lazy regarding tooth-brushing.
Self-efficacy
Three parents offered no ideas about how to reduce self-reported barriers to brushing. One
mother described it this way: If she doesn't want her teeth brushed, it will be a big struggle
that's like probably the biggest issue, cause you can't really like fight with a kid that's 3. If
they're not going to open their mouth, what are you going to do?
Skills
Only one parent mentioned skills as a barrier; she said she had not made twice-a-day tooth-
brushing a habit for her child.
External constraints
Thirty-nine of 44 parents described external factors that made twice-a-day brushing difficult.
The most common were struggles with a fussy or moody child and lack of time in a rushed
schedule. Brushing in the morning seemed to be particularly difficult to accomplish, as one
parent described: Well, in the morning, when I brush my teeth, he doesn't wake up in time so
it wouldn't be possiblehe barely gets up, so if I could possibly brush his teeth in the morning
I would.
Do supports or barriers differentiate parents who brush their young children's teeth twice a
day vs less often?
When the coded data were sorted to compare responses of parents who reported that their
children's teeth were brushed twice a day vs less often, the following patterns emerged. Parents
who brushed their children's teeth twice a day or more were more likely to describe utilizing
specific skills (eg, make it fun) or personal reminders to overcome barriers. Also, more parents
in the twice-a-day group expressed high self-efficacy for this task and high self-standards for
establishing it as a routine. Parents who brushed their children's teeth less than twice daily were
more likely to hold negative or false beliefs about the benefits of twice daily tooth-brushing,
report little normative pressure or social support for the behavior, have lower self-standards,
describe more external constraints, and offer fewer ideas to overcome barriers.
Discussion
This study's purpose was to describe the tooth-brushing experiences of rural infants and
preschool children to identify sources of support and barriers to twice daily brushing reported
by their parents. We chose a rural community as the study site because little is known about
the home oral health practices of rural caregivers. Tooth-brushing was chosen as the behavior
of interest because of persuasive evidence that early brushing with fluoridated toothpaste: is
associated with lower levels of mutans streptococci17; is highly protective of the teeth18-20;
predicts tooth-brushing habits in later childhood21-23; and is a very specific behavior amenable
to change.24,25
Approximately two thirds (26 of 41) of the parents who discussed the age at which they began
brushing their child's teeth said they began before the child's first birthday. No single
explanation emerged as a majority reason for initiating brushing. The most common reason
was an external cuethe eruption of the child's first tooth. The next most common reasons
reflected behavioral beliefs, followed by normative expectations including advice from early
childhood educators, health professionals, or peers.

Nearly all (91%) parents thought the recommendation to brush a child's teeth twice a day was
realistic. Only slightly more than half (55%), however, reported that they achieved this goal.
This finding could, in fact, be an overestimate due to social desirability response bias, a
limitation of research that relies on self-report. Other parent-reported tooth-brushing data are
similar. For example, Vargas and colleagues26 published a study of parents of children enrolled
in Head Start centers in Maryland in which 65% of parents reported brushing more than once
a day. The findings of Pine et al.6 included brushing frequency reported by parents of 3- to
4-year-olds; 50% of the US Caucasian sample reported brushing at least twice a day. Other
studies8 have reported that brushing frequency increases with child's age. We did not find this
to be true. In the present study, the ages of children whose parents said they had not yet begun
brushing their children's teeth ranged from 1- to 5-years-old.
Parents' responses to open-ended questions about sources of support and barriers to twice daily
tooth-brushing were analyzed using a mixed-model approach. At the conclusion of our open
coding, we organized the codes in terms of the integrative model and found that the 2 schemes
were congruent. Evidence for each behavioral determinant specified by the model was revealed
in the data. We also found considerable individual differences in what parents described as key
determinants. Information about determinants of tooth-brushing could be used to personalize
anticipatory guidance given in the dental office and, in turn, strengthen efforts to reduce ECC
This type of in-person counseling, called motivational interviewing, has been shown to be
superior to traditional health education strategies in encouraging a variety of caries-preventive
behaviors in parents of infants.27
Similar to other reports,8,28 many parents said they assisted their children with tooth-brushing.
Most often, however, assistance took the form of hands-off supervision; only 11 of 44 parents
actually brushed their child's teeth. Several parents described brushing as an activity the
children completed on their own. Other studies of mothers of older preschool children found
that nearly half describe their children as brushing on their own, without adult participation.
29,30 The present study confirms and extends this finding to even younger children. Based on
our data, it is clear that many parents do not recognize tooth-brushing as a self-help skill that,
like feeding or dressing, develops over time. Similar to those other skills, as the child matures,
parents' support must change from brushing their children's teeth to assisting with brushing
and brushing in tandem with their children before the child can do this independently. A child's
ability to carry out a thorough brushing without the parent's support depends on motor maturity
as well as cognitive and linguistic developments (eg, understanding the concepts of back and
front, inside and outside). It may be useful to recast tooth-brushing as a developmental skill
and teach parents how to support children's stages of learning.
The periodicity schedule for dental visits in the first few years of life recommends visits
beginning prior to 1-year-old and continuing twice yearly at minimum.31 This creates
numerous opportunities for dental professionals to influence home oral hygiene practices and
help parents recognize tooth-brushing as a self-help skill that, not unlike feeding or dressing,
improves with the child's motor, social, cognitive, and linguistic maturity.32 Anticipatory
guidance need not be confined to the dental office. Community-based early childhood
education programs such as Head Start are in a unique position to help ensure children receive
the benefits of tooth-brushing by incorporating supervised brushing in their program day and
by working with parents to help parents and children develop a twice-daily tooth-brushing
habit at home.33
Conclusions
Based on this study's results, the following conclusions can be made:

1. The determinants of parent-child tooth-brushing are multiple and vary from parent to
parent.
2. In this study, most parents reported brushing their young children's teeth but only half
reported brushing twice a day. Parents who achieved twice daily brushing were more
likely to discuss, accurately, milestones in child development, children's oral health
needs, and specific skills to engage the child's cooperation.
3. The most common barriers to brushing, cited by 89% of all parents, were lack of time
and an uncooperative child. Anticipatory oral health guidance for parents should
include discussion of ways to overcome these challenges.
Acknowledgments
We acknowledge support from the Northwest/Alaska Center to Reduce Oral Health Disparities (National Institute of
Dental and Craniofacial Research grant U54 DE14254). We thank the study's steering committee members,
interviewers, and other individuals who helped lead this research, particularly Cheri Raff and Nancy Keaton, and the
participating families who gave willingly of their time and expertise.
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Table 1
Summary of Reasons Parents Began Brushing Their Children's Teeth By Behavioral
Determinant Type
Behavioral determinant Example reasons % (count)*
Oral health beliefs Healthy teeth are important; brushing can help avoid cavities 25 (10)
Social norms Recommended by professionals or peers; child started brushing by imitating parents 18 (7)
Emotional reactions Poor oral health or painful experiences of self or others 10 (4)
Self standards It is yucky not to brush 13 (5)
Self-efficacy This is a routine I can establish 8 (3)
Skills Getting started in infancy is a good idea so the child gets used to brushing 3 (1)
External factors The child's first tooth appeared; I will begin with eruption of first tooth 18 (7)
*
Parents could report more than one reason for initiating brushing. Data are restricted to the 40 (of 44) parents who reported that they had begun
brushing their children's teeth.

Table 2
Frequency of Tooth-Brushing Currently By Child's Age
% (count)
All <1 y old 1-2 ys old 2 ys old

Current frequency of brushing (x/day) (N=44) (N=6) (N=12) (N=26)
Haven't started brushing 9 (4) 0 (0) 17 (2) 8 (2)

<1 2 (1) 0 (0) 0 (0) 4 (1)
1 34 (15) 17 (1) 42 (5) 34 (9)
2 50 (22) 83 (5) 33 (4) 50 (13)
3 5 (2) 0 (0) 8 (1) 4 (1)

Table 3
Facilitators and Barriers to Parent-Child Tooth-Brushing By Current Brushing Frequency
Determinants % (count)
Codes and example quotes of determinants as All Brushes <2/day Brushes 2/day
facilitators* (N=40) (N=16) (N=24)
Oral health beliefs 98 (39) 94 (15) 100 (24)

Oral health beliefs: You need to brush their teeth; that's really something you need to do for your kids so they don't have bad teeth later in life.
Social norms 65 (26) 56 (9) 71 (17)
Role models: It helps him to see all the other kids we live with brush their teeth; if the parent does it, the kids will do it. The kids go by example.
Social support: If he's not at my house, he's usually at grandpa's house, and they've been encouraging him to brush his teeth more.
Emotional reactions 45 (18) 50 (8) 42 (10)
Fear of consequences: A really scary picture of horrible decay might get me to be more regular about brushing.
Self standards 83 (33) 56 (9) 100 (24)
Self-standards: I grew up in a family that didn't brush their teeth and I am trying to do better than my parents.
Self-efficacy 18 (7) 0 (0) 29 (7)
Make it routine: It's something that you just have to do. It's just, you know, part of the routine, and it's like if your kid doesn't like vegetables,
you have to give vegetables.
Got it figured out: We just don't have a problem with this.

Skills 35 (14) 31 (5) 38 (9)
Make it fun: They were telling him to open his alligator mouth to make it a game for him. It was fun for him.
Use reminders: It's not really difficult because we have a list at home that they make a checkmark by.
Provide an incentive: Maybe if they do it, then I'll just give 'em 5 bucks at the end of the week.
Vary location: Sometimes I run late, and I'll put toothbrushes in the car. I brush her teeth out in the parking lot.
External support 38 (15) 44 (7) 33 (8)
Child cooperates: He likes to do it, that's what makes it easier. 'Cause when he wants to do it, he'll do it.
Variety of supplies: We just got a vibrating one [toothbrush]He like actually really likes that kind of stuff.
barriers (N=44) (N=20) (N=24)
Oral health beliefs 16 (7) 25 (5) 8 (2)

Oral health beliefs: People say that if you brush more than you're supposed to, it picks off the enamel or something.
Social norms 36 (16) 45 (9) 29 (7)
It's just me: It's just coming down to basically her and I.
Emotional reactions 11 (5) 10 (2) 13 (3)

Avoid distress: It's kind of distressinghim being so resistant.
Self standards 25 (11) 45 (9) 8 (2)
Less is good enough: If I get them once before bed, I think it's better than forgetting.
Lazy: I'm just lazy, I guess.
Self-efficacy 7 (3) 0 (0) 13 (3)
No idea: I have no idea what would help.
Skill 2 (1) 0 (0) 4 (1)
Not a habit: I haven't made it a habit
External constraints 89 (39) 95 (19) 83 (20)
Child doesn't cooperate: She's hard to keep still. She's a very active child and doesn't want to sit there.

Determinants % (count)
facilitators* (N=40) (N=16) (N=24)
Time: But then he barely gets up, so if I could possibly brush his teeth in the morning I would. But I can't.
*
Parents could report more than one facilitator of brushing. Data are restricted to the 40 (of 44) parents who reported that they had begun brushing
their children's teeth.

Parents could report more than 1 barrier to brushing. All 44 parents were included in the analyses of barriers to brushing.

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Pediatr Dent. 2010 ; 32(1): 4855.

Behavioral Determinants of Brushing Young Children's Teeth:

Colleen E. Huebner, PhD, MPH1 and Christine A. Riedy, PhD, MPH2

Pediatric Dentistry and of Family and Child Nursing

Correspond with Dr. Huebner at colleenh@u.washington.edu.

of Children's Health, a telephone survey conducted on over 100,000 US parents of children

An individual's intention to perform a behavior can be impeded, however, by external

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

habit of twice daily parent-child tooth-brushing?

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

seven of the 44 children described in the study were boys.

Initiation and frequency of parent-child tooth-brushing

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

Who does the brushing?

Determinants of current tooth-brushing

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

brushing, were excluded.

Oral health beliefs

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

Oral health beliefs

to basically her and I.

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

behaviors in parents of infants.27

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

streptococci infection in young children. Pediatr Dent 2003;25:2238. [PubMed: 12889697]

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

Behavioral determinant Example reasons % (count)*

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

All <1 y old 1-2 ys old 2 ys old

Haven't started brushing 9 (4) 0 (0) 17 (2) 8 (2)

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

Oral health beliefs 98 (39) 94 (15) 100 (24)

Got it figured out: We just don't have a problem with this.

Oral health beliefs 16 (7) 25 (5) 8 (2)

Emotional reactions 11 (5) 10 (2) 13 (3)

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

facilitators* (N=40) (N=16) (N=24)

Pediatr Dent. Author manuscript; available in PMC 2010 September 15.

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