Insisiva Dental Journal: Majalah Kedokteran Gigi Insisiva, 11(1), May 2022, 8-12 8 Research Article Parenting Styles and Dental Caries among Preschool Children in a Coastal Area of Jember, Indonesia Elyda Akhya Afida Misrohmasari1*, Berlian Prihatiningrum2 1Department of Dental Public Health, Faculty of Dentistry, Universitas Jember, Jl Kalimantan No 37, Jember 68121, Indonesia 2Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Jember, Jl Kalimantan No 37, Jember 68121, Indonesia Received date: March 31th, 2022; revised date: April 24th, 2022; accepted: May 23rd, 2022 DOI: 10.18196/di.v10i1.14385 Abstract Dental caries is a multifactorial condition affected by behavioral factors. Parenting styles reflect different behavior influenced by cultural and socioeconomic backgrounds. Coastal areas have unique cultural and socioeconomic conditions and underlie the community's upbringing behavior. This study aims to determine the differences in preschool children's caries experience based on parenting patterns in a coastal area. This research is a cross- sectional study on children and their parents in the coastal area of Puger, Jember, East Java, Indonesia. The participants were 269 pairs of preschool children and parents selected by random cluster sampling. The dependent variable was dental caries experience measured using the def-t index. The independent variable was the type of parenting categorized into three groups (authoritative, authoritarian, permissive) based on a questionnaire distributed to parents. The Kruskal-Wallis test was applied to determine the difference in caries rates in each parenting style (p≤ 0.05). The results showed that the prevalence of primary teeth caries was 97%, and the mean of def-t was 10.03. Authoritative parenting style was the majority (81.8%), and no statistically significant difference was found between caries and parenting style (p=0.473). However, the mean of def-t in the authoritarian group was higher than in others (10.42). Based on the result, it can be concluded that the mean of dental caries among children in a coastal area with authoritarian parents was the highest compared to others, but the difference was statistically insignificant. Keywords: coastal area; dental caries; parenting style INTRODUCTION Dental caries are the most common oral health problem globally. The Global Burden of Disease Study in 2019 showed that around 520 million children around the globe experienced caries of primary teeth.1 The prevalence of oral health problems continues to increase in most low and middle-income countries due to changes in living conditions and growing urbanization.1 In Indonesia, the prevalence of dental caries in 2018 was 81.8% among children 3-4 years and 92.6% among children 5-9 years old.2 Studies found that behavioral factors were found to be related to caries in * Corresponding author, e-mail: elyda.fkg@unej.ac.id children.3,4 Parents play an important role in shaping children's oral health behavior. Parents’ oral health attitudes and practices were related to children's oral health status.5,6 Moreover, oral health condition at an early age was related to oral health condition later in life.7 Therefore, promoting oral health behavior at an early age is important to improve quality of life.6 Children's oral health behavior is affected by how children are nurtured at home. Parenting styles have been divided into three categories, namely, authoritarian, permissive, and authoritative.8 The authoritarian parenting style shows high control and is less friendly in interacting Elyda Akhya Afida Misrohmasari & Berlian Prihatiningrum | Parenting Styles and Dental Caries among Preschool Children in a Coastal Area of Jember, Indonesia 9 with the child. The permissive parenting style showed non-responsive and non- controlling and made few demands on their child. The authoritative parenting style showed controlling but also receptive and warm to the child.8 According to Bronfenbreener (1979), parenting styles can be influenced by culture, ethnicity, and socioeconomic status.9 Coastal communities may have a distinctive parenting style influenced by local culture. The local coastal population is less able to process natural resources than the outsiders, so they mostly work as fishing laborers.10 The poverty causes many coastal parents to marry off their daughters at younger ages. Most of the girls are still teenagers, and they may be unable to continue their education or find a decent occupation.11 Parents learn from the local culture about the role they must play in raising their children.11 Based on the background, this study aims to analyze the difference in caries experience in primary teeth among preschool children based on parenting styles in the coastal area of Puger, Jember, Indonesia. MATERIALS AND METHODS This cross-sectional study examined preschool children and their parents in the coastal area of Puger, Jember, Indonesia. The coastal area of Puger is located in two villages, namely Puger Kulon and Puger Wetan. Ethical approval was given by The Ethical Committee of Medical Research Faculty of Dentistry Universitas Jember No. 238/UN.25.8/KEPK/DL/2019. Written consent was obtained from every child’s parent or caregiver. This study randomly sampled children enrolling at preschools in the Puger Kulon and Puger Wetan. There were 16 preschools in these villages with a total of 780 students. The sample size was calculated with a 95% confidence interval and a 5% margin of error. The minimum sample size needed was 258 preschool children. Preschools as the cluster were randomly selected from this area. All the eligible students from the selected schools were included in this study. The inclusion criteria for this study were children aged 4-6 years and parents' consent for involvement in the study. The exclusion criterion was uncooperative children for clinical examination. Nine preschools with 269 pairs of student- parents participated in this study. Data on caries were collected through children’s clinical examinations and a set of questions administered to mothers or caregivers. The clinical examination was performed with artificial light, a mouth mirror, a dental explorer, and relative isolation. The questionnaire consisted of a section on the sociodemographic characteristic of the parents and a section on parenting styles. The dependent variable in this study was the experience of dental caries in primary teeth, which was measured using the decay-exfoliated-filling (def-t) index. The independent variable was the parenting styles given to the mother or caregiver. The questionnaire on parenting styles consisted of 25 questions on parents' attitudes and practices regarding children's upbringing. The questions were multiple-choice questions with three choices. The choices indicated different categories for parenting styles. Participants' parenting style was categorized based on most answers to all questions. The researchers also conducted a pilot study in a preschool with 30 children involved to ensure the validity and reliability of the instruments. Data analysis was performed using SPSS version 25. Children and parents with missing data were excluded from the analysis. A Kruskal-Wallis test was used to determine the difference in the average ef-t scores for every parenting style. The level of significance for the test was ≤ 0.05. RESULT A total of 269 children participated in this study, consisting of 127 males and 142 females, as shown in Table 1. The Insisiva Dental Journal: Majalah Kedokteran Gigi Insisiva, 11(1), May 2022, 8-12 10 children's age in this study was mostly 6 years old (60.6%), and the majority were Javanese (95.9%). Most children had mothers with a primary level of education (41.6%) and lived with a family income of less than 1.5 million Indonesia Rupiah per month (69.5%).In this study, mothers were mostly housewives (90.7%). Table 1. Sociodemographic Characteristics of Respondents No Characteristics N (%) 1 Gender a. Male 127 47.4% b. Female 142 52.6% 2 Age a. 4 years 9 3.3% b. 5 years 97 36.1% c. 6 years 163 60.6% 3 Ethnicity a. Javanese 258 95.9% b. Madurese 11 4.1% 4 Mother's Education a. ≤ Primary 112 41.6% b. Junior high school 110 40.9% c. Senior high School 43 16.0% d. Higher edu 4 1.5% 6 Mother's Occupation a. Housewives 244 90.7% b. Self employee 18 6.7% c. Employee 7 2.6% 7 Family Income/Month (IDR) a. < 1.5 Million 187 69.5% b. 1.5– 2.49 Million 67 24.9% c. 2.5– 3.49 Millon 10 3.7% d. > Rp3.49 Million 5 1.9% Total 269 100% The prevalence of caries in primary teeth in this study was 97.0%, and the mean def-t score was 10.05 (standard deviation (SD)=4.68). As presented in Table 3, there were no significant differences between the three parenting styles regarding def-t score (p=0.473). The mean def-t score in the permissive group was 8.74, the lowest among all groups. In the authoritarian group, the def-t score was 10.42, the highest compared to the other groups. Table 3. Distribution of def-t according to Parenting Style No Parenting Style N def-t score P 1 Authoritative 220 10,14 0.473 2 Authoritarian 26 10.42 3 Permissive 23 8.74 Total 269 DISCUSSION The prevalence of caries in primary teeth (97%) and the mean def-t score were high in this study (10.05). Previous studies in coastal children aged 5-11 in Pakistan showed a lower prevalence at 70.8%12. Furthermore, a study using def-t index conducted on 6-year-old coastal children in Makasar, Indonesia, was 5.6.13 The association of parenting style with caries of primary teeth could not be determined in this study due to the insignificant difference in def-t scores between all three parenting groups. Insignificant differences in caries status in parenting styles were also found in a study of 4-6-year-old children in Korea.14 This study revealed that the highest mean of the def-t index was among the authoritarian parents. Previous studies demonstrated that the authoritarian parenting styles that were coercive and oppressive did not help to improve children's oral health.14,15 In this present study, in the children of permissive parents, the def-t index was lower compared to the other groups. However, a study in Korea reported that the children's caries were lower in authoritative parenting styles.14 This different finding may be related to the different cultures of the study population. Dental caries in children are associated with many factors, including oral health-related behavior, socioeconomic status, ethnicity, and birth order.16 Even though the importance of parenting styles in children was undervalued compared to these factors, oral health service providers should play a role in identifying and guiding the parenting Elyda Akhya Afida Misrohmasari & Berlian Prihatiningrum | Parenting Styles and Dental Caries among Preschool Children in a Coastal Area of Jember, Indonesia 11 style in the community health centers or any dental office. In terms of the limitation of this study, since the questionnaire was self- reported, the parents might provide false answers or be unfaithful when answering questions. Therefore, the distribution of parenting styles might be biased toward one side of the parenting style. In future studies, in-depth interviews can be added as instruments to access parenting styles. CONCLUSION Based on the result of this study, it can be concluded that this study found no statistical difference between dental caries in primary teeth and parenting styles. Authoritarian parenting style showed the highest def-t index among all groups. ACKNOWLEDGMENT We would like to acknowledge Siti Fatimah Khaerun Nisa for her contribution to collecting the data in this study. REFERENCES 1. Global Burden of Disease Collaborative. Global Burden of Disease Study 2019 (GBD 2019).; 2020. http://ghdx.healthdata.org/gbd- results-tool 2. Pusat Data dan Informasi Kemerterian Kesehatan RI. Kesehatan Gigi Nasional.; 2019. https://pusdatin.kemkes.go.id/article/v iew/20031000001/kesehatan-gigi- nasional.html 3. Elamin A, Garemo M, Gardner A. Dental caries and their association with socioeconomic characteristics, oral hygiene practices and eating habits among preschool children in Abu Dhabi, United Arab Emirates—the NOPLAS project. BMC Oral Health. 2018;18(1):1-9. https://doi.org/10.1186/s12903-018- 0557-8 4. Mwakayoka H, Masalu JR, Kikwilu EN. Dental caries and associated factors in children aged 2-4 years old in Mbeya City, Tanzania. J Dent. 2017;18(2):104. 5. Lotto M, Strieder AP, Ayala Aguirre PE, et al. Parental perspectives on early childhood caries: a qualitative study. Int J Paediatr Dent. 2020;30(4):451- 458. https://doi.org/10.1111/ipd.12622 6. dos Santos Costa F, Agostini BA, Schuch HS, Correa MB, Goettems ML, Demarco FF. Parent-child interaction and stimulation in early life can be related to caries in primary dentition? Hypotheses from a life-course approach. Med Hypotheses. 2019;130:109291. https://doi.org/10.1016/j.mehy.2019.1 09291 7. Misrohmasari EAA, Wicaksono D, Hadnyanawati H, Prihatiningrum B. Toothache experiences: findings from 21 years longitudinal survey. Brazilian J Oral Sci. 2022;21(00):e226288-. https://doi.org/10.20396/bjos.v21i00.8 666288 8. Viswanath S, Asokan S, Geethapriya PR, Eswara K. Parenting styles and their influence on child’s dental behavior and caries status: An analytical cross-sectional study. J Clin Pediatr Dent. 2020;44(1):8-14. https://doi.org/10.17796/1053-4625- 44.1.2 9. Luo S, Liu Y, Zhang D. Socioeconomic status and young children’s problem behaviours-- mediating effects of parenting style and psychological" Suzhi". Early Child Dev Care. 2019;191(1):148-158. https://doi.org/10.1080/03004430.201 9.1608196 10. Sebayang SK, Astutik E, Dewi DMSK, Mandagi AM, Puspikawati SI. Health care-seeking behaviour of coastal communities in Banyuwangi, http://ghdx.healthdata.org/gbd-results-tool http://ghdx.healthdata.org/gbd-results-tool https://pusdatin.kemkes.go.id/article/view/20031000001/kesehatan-gigi-nasional.html https://pusdatin.kemkes.go.id/article/view/20031000001/kesehatan-gigi-nasional.html https://pusdatin.kemkes.go.id/article/view/20031000001/kesehatan-gigi-nasional.html https://doi.org/10.1186/s12903-018-0557-8 https://doi.org/10.1186/s12903-018-0557-8 https://doi.org/10.1111/ipd.12622 https://doi.org/10.1016/j.mehy.2019.109291 https://doi.org/10.1016/j.mehy.2019.109291 https://doi.org/10.20396/bjos.v21i00.8666288 https://doi.org/10.20396/bjos.v21i00.8666288 https://doi.org/10.17796/1053-4625-44.1.2 https://doi.org/10.17796/1053-4625-44.1.2 https://doi.org/10.1080/03004430.2019.1608196 https://doi.org/10.1080/03004430.2019.1608196 Insisiva Dental Journal: Majalah Kedokteran Gigi Insisiva, 11(1), May 2022, 8-12 12 Indonesia: Results of a cross-sectional survey. J Ners. 2017;12(1):66-73. https://doi.org/10.20473/jn.v12i1.4439 11. Sary YNE. Relationship of parenting and social support for working single mothers on the provision of balanced nutrition and nutritional status of early childhood in coastal areas. Al-Athfal J Pendidik Anak. 2020;6(2):175-186. https://doi.org/10.14421/al- athfal.2020.62-07 12. Patoli S, Jabeen N, Zareef U, Hameedi S, Arshad MB, Farid H. Prevalence of dental caries among 5–11-years-old children in Ibrahim Hyderi, coastal area of Karachi. Found Univ J Dent. 2021;1(1):25-31. https://doi.org/10.33897/fujd.v1i1.265 13. Damayanti L, Zulkifli A, Amiruddin R, Palutturi S. Influence of food consumption to caries at school age in Ujung Tanah subdistrict. Enfermería Clínica. 2020;30:182-186. https://doi.org/10.1016/j.enfcli.2019.1 0.065 14. Lee M, Tak M, Kim J, Yang Y, Lee D. J Korean Acad Pediatr Dent. 2020;47(1):78-86. https://doi.org/10.5933/JKAPD.2020.4 7.1.78 15. Kumar S, Tadakamadla J, Zimmer‐ Gembeck MJ, Kroon J, Lalloo R, Johnson NW. Parenting practices and children’s dental caries experience: a structural equation modeling approach. Community Dent Oral Epidemiol. 2017;45(6):552-558. https://doi.org/10.1111/cdoe.12321 16. Tinanoff N, Baez RJ, Diaz Guillory C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. Int J Paediatr Dent. 2019;29(3):238-248. https://doi.org/10.1111/ipd.12484 https://doi.org/10.20473/jn.v12i1.4439 https://doi.org/10.14421/al-athfal.2020.62-07 https://doi.org/10.14421/al-athfal.2020.62-07 https://doi.org/10.33897/fujd.v1i1.265 https://doi.org/10.1016/j.enfcli.2019.10.065 https://doi.org/10.1016/j.enfcli.2019.10.065 https://doi.org/10.5933/JKAPD.2020.47.1.78 https://doi.org/10.5933/JKAPD.2020.47.1.78 https://doi.org/10.1111/cdoe.12321 https://doi.org/10.1111/ipd.12484