Oral health has been identified as an important public health issue by the World Health Organization (WHO).1 One of the focuses of the WHO oral health preventative strategies is to prevent dental caries among all population and social groups.2 Apart from reducing sugar intake,3,4 tooth brushing is another effective self-care strategy.4The New Zealand Ministry of Healths advice on tooth brushing is to brush at least twice daily.5 The expert advisory group of the New Zealand Guidelines Group provides further advice around the use of fluoride toothpaste; specifically, toothpaste of at least 1,000 parts per million (ppm) of fluoride is recommended for all ages. This amount of fluoride is equivalent to 0.76% sodium monofluorophosphate, or 0.221% sodium fluoride. It is also recommended that toothpastes labelled as child strength should be avoided for all ages because of their low level of fluoride. In terms of amount, for children up to the age of 5 years old, a smear of toothpaste should be used.6Findings from the 2009 Oral Health Survey indicated that, despite the Ministry of Healths recommendation on tooth brushing,5 only two-third of preschoolers aged 2-4 years (66%) brushed their teeth at least twice daily. The proportion of those who brushed twice daily with fluoride toothpaste was only at 15%.7Similar to other countries, in New Zealand a wide range of toothpastes are available for purchase. This includes full-strength toothpastes that are not age-specific, as well as those that are labelled for babies or children, or as natural or herbal toothpastes. The strength of fluoride varies hugely, with those labelled for babies/children or as natural/herbal typically containing less fluoride (or no fluoride at all).While the Ministry of Health5 endorses the New Zealand Guidelines Groups recommendation of all people using full-strength toothpaste,6 there is no published data on the use of different types of toothpastes among New Zealanders.8 This study fills this information gap by collecting data on the use of different types of toothpastes by preschoolers in New Zealand, and the factors determining toothpaste choice as reported by their parents or caregivers. This information can then be used to inform public health initiatives to enhance the parents and caregivers health literacy in relation to toothpaste usage and improve the oral health of young New Zealanders.MethodsParticipantsThe research population for the study was parents and caregivers of preschoolers, operationally defined as those aged between 4 months and 4 years 11 months old. To be eligible to take part, participants must be 18 years old and over, and responsible for providing regular care and/or guardianship for the preschoolers .Using an identical methodology as the main study, the questionnaire was piloted with 56 respondents. Prior to the commencement of the study, there was an expected sample size of 1,000 for the main survey. No change was made to the recruitment protocol or the questionnaire after the pilot, and therefore responses from the pilot were included in the analysis. This decision resulted in a total of 1,056 participants in the final sample. Ethics approval for this study was obtained from the New Zealand Ethics Committee (Ref: NZEC 15 #23).Sampling procedureA convenience sample of parents and caregivers were recruited from an online research panel called Consumer Link. Potential participants received an email invite and received points on completion of the online survey. The points are accumulated and can be redeemed for products or services. Prior to participation, potential respondents were informed that their participation was voluntary. Informed consent was indicated by respondents selecting a tick box to represent their willingness to participate. The response rate was 78%.AnalysisThe analysis was undertaken using STATA IC 13.1. A total of 50 respondents indicated that the preschoolers under their care did not have any teeth, and a further 22 reported that their preschoolers did not use toothpaste. The questions on toothpaste were irrelevant to this group of respondents, and therefore they were not asked in the survey. This reduced the number of cases for the analysis to 984.The dependent variables were: a) the type of toothpaste used by the preschoolers; and b) the factors parents/caregivers considered when they chose toothpastes for their preschoolers . For both variables, descriptive statistics were calculated. In-depth analysis was also carried out with the first variable, to help with the understanding of factors that were associated with an increased likelihood of using full-strength fluoride toothpastes.This was undertaken using univariate and multivariate logistic regression models.ResultsSample characteristicsSocio-demographic characteristics of the total sample and the sub-sample are described in Table 1. A large majority of the adult respondents were females (87%) and the biological parent of the preschoolers (95%). Only 7% and 2% of adult respondents self-identified as M1ori or Pacific (when prioritised in the order of M1ori, Pacific, and European/other). In terms of the preschoolers characteristics, there was an even representation of both boys and girls, and the first and subsequent child of their parents. Table 1: Socio-demographic characteristics of the adult respondents and the child under their care. Total Sample n=1,056 Sub-sample (children with 1+ teeth and used toothpaste) n=984 Adult characteristics n % n % Gender Male 138 13.1 126 12.8 Female 918 86.9 858 87.2 Ethnicity (prioritised) M1ori 76 7.2 72 7.3 Pacific 16 1.5 15 1.5 New Zealand European/ Other 964 91.3 897 91.2 Age group 18-24 years 11 1.0 10 1.0 25-34 years 474 44.9 435 44.2 35-44 years 518 49.1 490 49.8 45-54 years 40 3.8 39 4.0 55+ years 13 1.2 10 1.0 Relationship to the child Biological parent 1,003 95.0 934 94.9 Mothers/fathers partner 26 2.5 25 2.5 Grandparent 14 1.3 12 1.2 Foster parent 7 0.7 7 0.7 Legal guardian 5 0.5 5 0.5 Aunt 1 0.1 1 0.1 Household equivalised income <$40,000 63 6.0 57 5.8 $40,001-$70,000 254 24.1 233 23.7 $70,001-$100,000 276 26.1 259 26.3 $100,001+ 360 34.1 336 34.2 Dont know 103 9.8 99 10.1 Child characteristics n % n % Gender Male 527 49.9 489 49.7 Female 529 50.1 495 50.0 Ethnicity (prioritised) M1ori 138 13.1 128 13.0 Pacific 31 2.9 28 2.9 New Zealand European/ Other 887 84.0 828 84.2 Age group 4-6 months 46 4.4 6 0.6 7-11 months 47 4.5 23 2.3 1 year 227 21.5 220 22.4 2 years 262 24.8 261 26.5 3 years 278 26.3 278 28.3 4 years 196 18.6 196 19.9 First child of the adult Yes 532 52.9 508 54.2 No 474 47.1 429 45.8 Type of toothpaste currently used by the childTwo respondents did not know the type of toothpastes that was used by the preschool child, and their responses were excluded from the analysis on this specific measure (n=982). Overall, only 19% of the preschoolers in our sample used full-strength fluoride toothpaste. Half of them used toothpastes labelled as suitable for children.The odds ratios generated from the univariate logistic regression models suggested that the likelihood of preschoolers using full-strength fluoride toothpastes did not differ by the preschoolers demographic characteristics, adults ethnicity, or perceived oral health of the child, as reported by the adult. However, preschoolers had increased likelihood of using full-strength fluoride toothpastes if they were not the first child of their parents (OR=1.77, 95% CI=1.28-2.47) or if they had ever visited a dental professional (OR=1.84, 95% CI=1.18-2.85). Because of the potential association between dental visit and the childs age, a multivariate logistic regression model was also computed. After controlling for age, having visited a dental professional still predicted the use of full-strength toothpaste (AOR=1.95, 95% CI=1.21-3.16).Other than birth order and dental visit, the use of full-strength fluoride toothpastes was also associated with agreement with the statement, \u201cit is important for children to use age-appropriate toothpaste\u201d. Preschoolers whose parents or caregivers did not agree with this statement had 19-fold increased odds (95% CI=11.91-30.71) of using full-strength fluoride toothpaste (see Table 2). Table 2: Type of toothpaste currently used by the child, reported by the parents/ caregivers (n=982). Toothpaste for babies (n=222) Toothpaste for children (n=535) Non- fluoridated / natural toothpaste (n=40) Full- strength fluoride toothpaste (n=185) Odds ratio (using full-strength fluoride toothpaste) Overall 22.6 54.5 4.1 18.8 - Childs gender Male (n=488) 23.0 57.0 3.7 16.4 1 Female (n=494) 22.3 52.0 4.5 21.3 1.38 (1.00-1.90) Childs ethnicity M1ori (n=128) 25.8 50.0 5.5 18.8 1 Non-M1ori (n=854) 22.1 55.2 3.9 18.9 1.01 (.63-1.62) Adults ethnicity M1ori (n=72) 25.0 48.6 5.6 20.8 1 Non-M1ori (n=910) 22.4 54.9 4.0 18.7 .87 (.48-1.59) Childs age 4-6 months (n=6) 16.7 66.7 0.0 16.7 1 7-11 months (n=23) 43.4 43.5 0.0 13.0 .75 (.06-8.83) 1 year (n=220) 40.5 39.1 3.6 16.8 1.01 (.11-8.91) 2 years (n=259) 25.5 50.6 3.1 20.8 1.32 (.15-11.51) 3-4 years (n=474) 11.8 64.1 5.1 19.0 1.17 (.14-10.15) First child of the adult (n=959) Yes (n=507) 25.4 55.4 4.1 15.0 1 No (n=428) 19.4 52.9 4.0 23.8 1.77 (1.28-2.47) Perceived oral health status (n=982) Excellent/ very good (n=879) 23.1 54.2 4.0 18.8 1 Good/fair/ poor (n=101) 17.8 58.4 5.0 18.8 1.00 (.59-1.70) Child had visited a dental professional (n=971) No (n=755) 38.4 44.9 4.2 12.5 1 Yes (n=216) 18.1 57.0 4.1 20.8 1.84 (1.18-2.85) Agreed that it is important to use age-appropriate toothpaste (n=946) No (n=362) 9.1 43.1 5.0 42.8 19.13 (11.91-30.71) Yes (n=584) 31.0 61.6 3.6 3.8 1 Note: Statistically significant difference at p<0.05 are denoted in bold. Table 3: Reasons for choice of toothpaste (n=974). Reasons (multiple reasons allowed) % A brand I trust 58.6 Matches my childs age 49.4 A taste my child likes 25.1 Cheaper price/ discounted 18.0 Contain a low level of fluoride 15.7 A cartoon character/ picture my child likes 13.5 To have one toothpaste for the whole family 12.2 Other reasons 10.6 Contain no fluoride 4.2 Number of response options selected: Range = 1 to 7 Mean = 2.1Factors determining toothpaste choiceTen respondents indicated that they were not responsible for choosing toothpastes for their preschoolers, and were not asked the question on what factors they considered when choosing toothpaste for their preschoolers. The remaining respondents (n=974) were asked to select from a list of nine factors, and multiple responses were allowed.The number of factors selected by respondents ranged from one to seven; 38% of respondents selected only one factor and 31% selected two (see Table 3). The most commonly cited factor was a brand that they trust (59%), followed by choosing a toothpaste that matches the childs age (49%). One-quarter of respondents commented on taste (25%), while one-fifth commented on price (18%). Having one toothpaste for the entire family was only mentioned by 12% of the respondents, and 11% mentioned there were other reasons affecting their choice. However, the questionnaire did not require respondents to indicate what the other reasons were.DiscussionDespite the Ministry of Healths recommendation on the use of full-strength fluoride toothpaste for all ages,5 our data indicated that only 19% of the preschoolers in the sample used this type of toothpaste. Our data suggested that the low update of full-strength fluoride toothpaste could be attributed to parents and caregivers lack of knowledge around toothpaste use among preschoolers.Direct evidence could be drawn from the strong inverted relationship between parents and caregivers belief that children should use age-appropriate toothpaste and the use of full-strength fluoride toothpaste. Less direct evidence came from the differences found among first and subsequent children, with subsequent children being more likely to use full-strength fluoride toothpaste. Differential level of parental knowledge and behaviours associated with preschool oral health has been well documented in a previous New Zealand study9 and international literature.8,10 For example, a study conducted with 104 pregnant women in Dunedin found that overall, there was a low level of knowledge on preschool oral health care. The researchers in this study showed that there was a lack of knowledge of when tooth brushing should begin, or when preschoolers should have their first dental visit. This was particularly true among women who were first-time mothers, young, or with a low socio-economic status.9The other factor that was associated with the use of full-strength fluoride toothpaste was dental visits, with preschoolers who had ever visited a dental professional having increased odds of using full-strength toothpaste. This finding might suggest that dental professionals are an important information source for parents and caregivers on toothpaste choice; however, the first dental visit might happen too late to provide timely oral health advice to parents and caregivers. There is currently no population-based data on the proportion of preschoolers in New Zealand who have ever visited a dental professional. The 2009 Oral Health Survey had collected data on dental visit in the past 12 months, and found that only 60% of two-to-four year olds had done so.7The results from the current study also demonstrated the lack of awareness amongst the participants of the Ministry of Healths recommendation around toothpaste. From a list of nine reasons, the Ministrys recommendation on having one toothpaste for the whole family ranked seventh. In contrast, choosing an age-appropriate toothpaste was the second most commonly-selected reason, at 49%. To put our findings into context, three previous studies were conducted in Asia where parents selected from a list of factors that affected their toothpaste choice for their children. The actual proportion of parents who chose toothpaste for their children based on the fluoride concentration varied hugely across studies: 12% in India,11 61% in China,12 and 85% in Malaysia.13 Importantly, fluoride concentration was notthe most commonly cited reason in any of these studies.11-13 Factors that were more commonly reported were brand, taste, and advice and recommendations from friends, family and dental professionals. The consistency across studies around the relatively low priority given on fluoride concentration suggest this might be a universal issue.In New Zealand, part of the confusion on toothpaste choice could arise from manufacturers instructions on toothpaste packaging being inconsistent with the Ministry of Healths recommendations. Future studies may investigate the extent to which parents and caregivers read and adopt the tooth brushing information printed on toothpaste packaging. In terms of health promotion strategies, it is important to recognise the different messaging parents and caregivers are exposed to around toothpaste types.Explicit information that would allow parents and caregivers to distinguish messaging from different sources, and to comply with the Ministry of Healths recommendations might be required.The responses to the type of toothpaste currently used by the sampled preschoolers and the parents or caregivers criteria for choosing toothpaste were consistent. It appeared that there is a need to improve parents and caregivers knowledge level to ensure they adopt the Ministry of Healths recommendations. While dental professionals could be an important channel to provide oral health information to parents and caregivers, advices delivered by a range of other health professionals who engage with parents and caregivers at an earlier stage\u2014such as lead maternal carers, Well Child providers, or public health nurses\u2014could also be beneficial. The study conducted in Dunedin has found that pregnant women were receptive to the idea of receiving oral health information from Plunket nurses, general medical practitioners, dentists and midwives.24 A number of overseas studies have found oral health interventions delivered during pregnancy effective. These interventions also had a focus on improving the oral health of the women.10,14,15Strengths and limitationsThis study provided novel information around the type of toothpastes used by preschoolers in New Zealand, and the findings had important implications on both oral health literacy and promotion. A lot of the literature in preschool oral health has focused on mothers, as they have been identified as playing a key role in the general health and wellbeing of their children. However, understanding the involvement of the wh1nau would help to address the wider household-related barriers for having good oral health practice. By giving the opportunity for both of the parents and caregivers to participate in this survey, we hope to fill in some of the existing knowledge gaps. This is particularly important in the New Zealand context as grandparents, aunties and uncles often play an important role as a main caregiver in M1ori and Pacific families.It is also important to acknowledge the limitations of the dataset. This includes the small Pacific and M1ori sample size. According to the 2013 New Zealand Census of Population and Dwelling, 7% of the New Zealand population are affiliated with at least one Pacific ethnicity (based on total ethnicity).16 The ethnicity composition of the parent and caregiver population in New Zealand is not known, however, the proportion of Pacific people within this sub-population is likely to be smaller than 7% due to the youthful nature of the Pacific population in New Zealand, when compared with other