Dental caries is the most prevalent non-communicable chronic disease in the world, according to the World Health Organization (1). The Brazilian National Oral Health Survey (SB BRASIL) conducted in 2010 shows that dental caries affects approximately 53.4% of 5-year-old children (2). Dental caries is a chronic multifactorial disease that develops through a dynamic interaction among tooth structures, biofilm, and sugars and it involves a continuous process of demineralization and remineralization of the tooth surface. When demineralization persists over time, carious lesions begin to form (3). In addition to factors such as poor dietary habits and oral hygiene, another predisposing factor contributing to the increase of dental caries in preschool children is maternal attitudes and knowledge about oral health (4–6). Fisher-Owens et al. in 2007 (7) proposed a conceptual model of factors influencing children's oral health: individual factors such as health behavior and practices, dental visits, physical and demographic attributes, for example; family factors such as socioeconomic status, parents' health status, social support, family composition and culture, among others. Furthermore, community factors such as the availability of dental and health services, social capital, and the overall social environment are also integral components of the model (7).

A recent systematic review of parental factors influencing the presence of dental caries in early childhood in developing countries suggests that income, education, knowledge of oral health, and attitudes are associated with the prevalence of this disease (8). Low parental literacy has been correlated with adverse outcomes in children's oral health. Furthermore, it is associated with practices that increase the risk of dental caries, including the consumption of cariogenic foods and beverages, inadequate use of fluoride toothpaste, and insufficient brushing habits (9–11).

During the preschool age, parents play a crucial role as mediators of information, behaviors, and decisions related to their child's health. Psychosocial factors, such as resilience and self-efficacy, emerge as significant mediators influencing oral health behaviors, including the pivotal decision to seek dental care (12, 13). Exploring actions and factors linked to parents' perceptions of their children's oral health is essential for identifying key indicators that may influence behaviors and approaches related to oral health maintenance. This understanding can directly impact practices like consistent diet control and the proactive pursuit of dental care. Therefore, the aim of this study was to evaluate family-related factors contributing to the prevalence of dental caries among 5-year-old children.

The study sample comprised of 578 pairs of participants (children and caregivers). The mean dmft index was 1.14 (SD = 2.24), while the SiC index was at 3.46 (SD = 2.69). The prevalence of dental caries experience was 32.7%.

Table 1 presents the results categorized according to the conceptual model of Fisher-Owens et al. 2007 (7), including child, family, and community levels. Among children with dental caries experience (dmft ≥ 1), 36.7% had not visited the dentist for more than 2 years. The majority (67.7%) of children whose parents reported daily tooth brushing habits remained free of dental caries. In contrast, children who consumed sugary foods and drinks three or more times a day exhibited a dental caries prevalence of 31.7%, while the majority (68.3%) of those consuming such items up to twice a day remained caries-free.

At the family level, when caregivers rated their own oral health as good/excellent, 71.2% of their children were caries-free. Additionally, children whose caregivers rated their oral health as good/excellent showed no dental caries (77.8%). Children whose parents who did not assist them with tooth brushing displayed dmft ≥ 1 (47.8%). Children from households with an income > R$3,000 (>US$600) showed better oral health, with 75.3% remaining cavity-free. Caregivers who stated that oral health was a priority exhibited better oral conditions for their children, with 68.6% being cavity-free and only 31.4% experiencing dental caries.

At the community level, 69.3% of children whose caregivers felt safe/moderately safe in their neighborhoods did not have dental caries. Most children whose parents reported that their neighborhood had playgrounds and parks did not have dental caries (69.2%).

Variables with p < 0.20 in the univariate analysis were included in the logistic regression models. The first model was adjusted for child's last dental visit, self-rated oral health perception, Parent's rating of child's oral health, assistance with toothbrushing, income, number of rooms in the residence, number of residents, number of residents under 18 years old, family meals, dental visit as a priority (Table 2). In the second model, besides the variables described before, we included the ones related to knowledge of dental caries (White spot as first sign of dental caries, Sugary foods/drinks cause dental caries) (Table 3). Among these variables, family factors such as income, involvement in child tooth brushing, perception of the child's oral health, and prioritization of dental treatment within the family, were found to be associated with the occurrence of dental caries. However, when variables related to knowledge of dental caries (recognizing the first signs of dental caries and understanding if sugary drinks/food cause the dental caries) were included in the logistic model construction, income was no longer retained in the final model, while perception of the parent's own oral health remained significant (Tables 2, 3).

According to the World Health Organization (WHO), dental caries affects approximately 2.3 billion people worldwide, with 53.4% of 5-year-old children in Brazil affected (2, 18). Beyond environmental factors, parental influences play a significant role in shaping children's oral health (8).

Our study findings revealed that familial factors, including income, involvement in children's dental brushing, perception of oral health, and prioritization of dental visits, significantly influence the presence of dental caries in preschool children.

Socioeconomic status plays a crucial role in dental caries, as evidenced in this study, where children from lower-income families were more likely to develop dental caries. This finding aligns with a study conducted in 2022 by Sultana et al., which found a significant association between low family income and the caries index, with these children being 4.75 times more likely to experience the disease (19). Additionally, association of income trajectories and dental caries was found in birth-cohort studies, with poverty at birth and throughout life being linked to higher numbers of decayed teeth (20, 21).

Socioeconomic status can indeed serve as a barrier to acquiring health knowledge. A recent study concluded that mothers with low income, who have children aged 3–5 years, often exhibit inadequate preventive behaviors for caries and fail to adopt sufficient practices to ensure their children's oral health (22). In a study conducted in Araçatuba, São Paulo, in 2010, the dmft index for 5-year-old children was 1.65 (SD = 2.67), with dental caries being significantly more prevalent in low-income children (23). In the present study, the dmft index found for 5-year-old children was 1.14 (SD = 2.24), and a higher proportion of children from lower-income families presented dental caries, consistent with the findings of previous studies. Interestingly when variables related to knowledge of dental caries were included in the logistic model, income did not remain a significant factor. Instead, parent's perception of their own oral health emerged as influential factor, together with involvement in child tooth brushing, parent's perception of child's oral health, and prioritization of dental treatment. These results suggest that other factors, that surpass socioeconomic factors, may play a role on dental caries experience, for example oral health literacy, attitudes, and practices in determining caries risk. The common risk approach shows that oral diseases share common risk condition with other chronic noncommunicable diseases (diabetes, obesity, stroke, i.e.,) (24). Living in unhealthy conditions may determine risk behaviors (25).

Ensuring proper dental brushing practices is crucial for maintaining good oral health, especially among children. Supervised brushing is particularly important for preschoolers, as their self-care abilities are still developing, resulting in poor quality brushing and sometimes incorrect techniques (26). The age at which children commence brushing, the frequency of brushing, and whether parents assess the effectiveness of their children's brushing directly influence the prevalence of early childhood caries (ECC) (27). In this study, children who received parental assistance during brushing demonstrated a reduced risk of developing dental caries, even when this assistance occurred only once a day on certain days of the week.

In a study aiming to quantify the association between caregivers' perception of their own oral health and that of their child, the authors noted a significant correlation between the caregivers' poor perception of their own oral health and that of their child (28). Similarly, in our study, caregivers demonstrated notable accuracy in assessing their child's oral health and current oral condition. Children whose caregivers reported a negative perception of their children's oral health exhibited a higher likelihood of experiencing dental caries.

Children whose caregivers did not prioritize a dental visit were approximately twice as likely to experience dental caries. During childhood, parents play a pivotal role in decision-making and shaping their child's habits, particularly concerning their oral health and dental care visits. Tooth brushing habits from parents that do not present depression reciprocally affect child's tooth brushing behaviors (29), as well as parent's tooth brushing behavior affects the tooth-brushing habits for their children (30). The education on prevention and oral hygiene of parents influence the oral health of children mainly when they receive individualized oral health education (31, 32). Oral health education should not be the sole responsibility of oral health care providers; instead, a collaborative effort among professionals from various fields may improve oral health in children and the general population (31, 33). To support this, oral health should be integrated into their curricula (34).

Several factors may contribute to parents not taking their children to the dentist. These reasons could include concerns about the child's behavior during dental visits, socioeconomic constraints due to the expenses associated with treatment, insufficient knowledge and awareness about oral health, and prevalent myths and misconceptions regarding oral health. One such misconception is the belief that baby teeth inherently do not necessitate treatment, as they are expected to shed naturally (35–37).

Parents may refrain from taking their children to the dentist for various reasons, including past negative experiences, psychological barriers, fear of pain, anxiety, and a lack of trust in dental professionals. However, the presence of a supportive and knowledgeable dental professional can play a crucial role in addressing these concerns, instilling confidence in parents and making them more inclined to seek dental care for their children when necessary (38). In addition to the reassurance provided by dental professionals, there is a pressing need to prioritize educational efforts aimed at both parents and children. By emphasizing the importance of oral health and providing motivation and encouragement, dental providers support caregivers to actively engage in their children's oral hygiene routines (39). Educational programs tailored to sensitize caregivers to the significance of dental care can equip them with the necessary information and resources to promote better oral health practices in their households. Ultimately, by fostering a collaborative approach that prioritizes education and support, we can strive to improve the oral health outcomes of children and alleviate barriers to accessing dental care.

Dental caries, a complex condition influenced by various factors, encompasses individual, familial, and community dynamics that contribute to its occurrence. While our study explores these factors, community-level variables did not emerge as significant predictors of dental caries presence. Interestingly, our findings revealed that most caregivers expressed a sense of security within their neighborhoods. Furthermore, they reported ample social interaction opportunities for children, such as playgrounds and parks. Despite these positive community aspects, the study did not uncover a significant association with the prevalence of dental caries. This suggests that while community factors play a role in shaping oral health outcomes, other individual and familial determinants may exert a more substantial influence. Further exploration is warranted to fully understand the interplay of these factors in the development of dental caries and to inform targeted intervention strategies.

This study presents some limitations. Firstly, the use of a self-administered questionnaire introduced the possibility of incomplete responses or multiple selections for questions requiring single responses. Additionally, the non-participation of all schools, coupled with the exclusive inclusion of public schools, poses a limitation. This selective sampling approach may limit the generalizability of findings, as the sample of 5-year-old children may not fully represent the broader population within the city, state, or country. Nevertheless, it is noteworthy that our study encompassed a substantial sample size of 578 5-year-old children, enabling robust statistical analyses with a high level of test power (99%). Despite the acknowledged limitations, the extensive sample size enhances the reliability of our findings and contributes valuable insights into the prevalence and determinants of dental caries among young children.

Family relationships play a pivotal role in fostering overall health and well-being, alongside the connections forged within the school environment and the broader community. Acknowledging the importance of these interconnected social networks, dental professionals serve as catalysts in establishing communication channels within communities. By engaging with social agents, dental professionals contribute to collective efforts in prioritizing and advancing oral health initiatives, ultimately benefiting individuals and families. However, to achieve significant oral health gains, these strategies should be complemented by a common risk approach within the community (25) and policies targeting social determinants of health (40).

In this population, a low prevalence of dental caries was observed, with familial factors showing an association with this condition. The attitudes of caregivers regarding oral health seem to exert a significant influence on the dental health of their children. Consequently, dental professionals are tasked with assuming an educational, motivational, and positive reinforcement role to cultivate attitudes conducive to improving and maintaining oral health. Through these efforts, dental professionals can contribute to shaping a family environment that prioritizes oral health promotion.