Community Dent Oral Epidemiol 2010; 38: 1018  2009 John Wiley & Sons A/S

All rights reserved

Kate A. Levin and Candace Currie

Adolescent toothbrushing and Child and Adolescent Health Research Unit,
University of Edinburgh, Edinburgh, UK

the home environment:

sociodemographic factors, family
relationships and mealtime
routines and disorganisation
Levin KA, Currie C. Adolescent toothbrushing and the home environment:
sociodemographic factors, family relationships and mealtime routines and
disorganisation. Community Dent Oral Epidemiol 2010; 38: 1018.
 2009 John Wiley & Sons A S

Abstract Objectives: Previous studies have shown that sociodemographic

factors are associated with adolescent toothbrushing. While there has been
some investigation of parental modelling of oral health behaviour and the
association between parental support and oral health, there has been no
investigation of the home environment and its effect on oral health behaviour.
The current study examines variables related to the family, including mealtime
routines and family relationships to determine the best predictors of adolescent
toothbrushing. Methods: Data from the 2006 Health Behaviour in School-Aged
Children Survey were modelled using logistic univariate and multivariable
modelling with outcome variable twice-a-day toothbrushing. Results: Higher
family socioeconomic and affluence were significantly associated with greater
odds of toothbrushing twice a day or more. Family structure was also
significantly associated with girls toothbrushing. However, under the
multivariable model, eating breakfast was found to be the best predictor of Key words: adolescents; dental health
twice-a-day toothbrushing among boys and girls. The next best predictor of promotion; oral health; oral hygiene;
boys toothbrushing was eating family meals and of girls toothbrushing, never public health
going to bed hungry, followed by family affluence for both boys and girls. Kate Levin, CAHRU, The Moray House
Under the multivariable model, family structure was no longer significantly School of Education, The University of
associated with girls toothbrushing. Conclusions: The study shows that the Edinburgh, St Leonards Land, Edinburgh
EH8 8AQ, UK
family and home environment should play a central role in the promotion of Tel.: +44 (0)131 651 6547
oral health, through mealtime routines, incorporating a fair parenting style and Fax: +44 (0)131 651 6271
developing open and positive family relationships. Not only are these strongly e-mail: kate.levin@ed.ac.uk
associated with twice a day toothbrushing but, unlike sociodemographic Submitted 15 April 2009;
factors, they may be relatively easy to adopt. accepted 5 September 2009

Dental disease amongst children and young people
in Scotland is high compared with the rest of the
United Kingdom and many Western European
countries (1). Frequency of toothbrushing and use
of fluorides are associated with dental caries and
general oral health (24) and it is recommended
that children brush their teeth at least twice a day
to reduce levels of tooth decay and gum disease
(5, 6), as oral hygiene habits are developed early in
life (7). Adolescents who brush their teeth more
than once a day by 12 years of age are more likely
to continue to do so throughout their teenage years
(8). Promoting toothbrushing from a young age is
therefore an important priority in Scotland. This is
particularly true among boys who have lower
twice-a-day toothbrushing rates compared with

10 doi: 10.1111/j.1600-0528.2009.00509.x

girls, not only in Scotland but in all countries (9).
Targets have been introduced to encourage local
initiatives aimed at children, including supervised
fluoride toothbrushing schemes for younger
children and oral health promotion programmes
in secondary schools (10). Previous child and
adolescent oral health research has examined the
impact of health promotion strategies on oral
health through, for example, randomised con-
trolled trials in schools or preschool community
settings. There has also been some work investi-
gating the context of the family, in particular the
relationship between sociodemographic factors
and oral health.
Socioeconomic (SES) inequalities in child and
adolescent oral health and oral health behaviour
have been shown previously in the literature both
in Scotland (11, 12) and elsewhere (9, 13). The
association between family structure and oral
health, however, has resulted in mixed findings.
While Maes et al. (9) found no significant associa-
tion between family structure and toothbrushing in
most countries, a number of other studies found a
significant relationship between family structure
and child and adolescent oral health outcomes (14
16). In Scotland, this was also true of toothbrushing
with higher odds of twice-a-day toothbrushing
among adolescents living in both parent families
compared with other family structures (11).
Ethnicity (13, 17) and household size number of
siblings (17, 18) have also been associated with
child and adolescent oral health.
As well as sociodemographic factors, parental
oral health behaviour is a known predictor of
offsprings caries experience in childhood (18) and
oral health behaviours during adolescence (19, 20).
Under the family socialization model, parents play
an important role in child development through
encouragement, support and modelling, where a
child adopts the behaviour of their parent. The
family is considered to be the most important agent
in socialization, especially during childhood and
early adolescence (21). Parental socialisation is
evident in respect to many other child and adoles-
cent health behaviours such as physical activity,
diet and smoking (2224).
Aside from parental oral health behaviour and
sociodemographic factors, however, few other
dimensions of the family and home environment
have been studied in relation to oral health behav-
iour. Astrom (20) found that where a child per-
ceived relationships with their parents to be
positive and close, higher oral hygiene scores were
Toothbrushing in adolescence and the family
achieved, while parental control or monitoring,
was not associated with oral hygiene. Ostberg et al.
(25) and Adair et al. (26) also found parental
support to be associated with perceptions of oral
health, while Sanders & Spencer (27) showed that a
positive and supportive parental rearing style
during childhood was associated with adult oral
health.
Routines and rituals are known to be key players
in the promotion of family identity, connectedness,
organisation and communication (28, 29), and are
associated with young peoples psychological
health (28, 30). Conversely, going to bed hungry,
also known as food poverty, is a measure of
family disorganisation and is related to poor
adolescent physical and mental health (31).
However, no study has looked at associations
between family routines and organisation and oral
health. This study therefore aims to look at
contextual variables related to the family that
predict twice-a-day toothbrushing among 1115-
year-old adolescents in Scotland, and to examine
whether mealtime routines and family relation-
ships mediate the relationship between socio-
demographic variables and toothbrushing.
Materials and methods
Study design
This paper examines Scottish data from the 2006
Health Behaviour in School-aged Children (HBSC)
survey. The research protocol was approved by
University of Edinburgh ethics committee. The
population was stratified by education authority
(the Council department responsible for publicly
funded schools in their area) and school type,
defined as either state-funded or independent
schools. A nationally representative sample of
Primary 7 (P7), Secondary 2 (S2) and Secondary 4
(S4) year groups was selected using systematic
random sampling and questionnaires were admin-
istered in schools between March and June so that
the average age of the groups sampled were 11.5,
13.5 and 15.5 years. The questionnaire was com-
pleted anonymously in class under teacher super-
vision. Response rate of schools was 76% and of
pupils 89% and the study sample size for boys
was n = 3063 and for girls n = 3127. More infor-
mation regarding sampling, recruitment and data
collection, including the rationale for these meth-
ods and validation of measures, is available
elsewhere (32).
11
Levin & Currie
Outcome variable
Young people taking part in the HBSC surveys are
asked how often they brush their teeth. Responses
are More than once a day, Once a day, At least
once a week but not daily, Less than once a week,
Never. The data were re-coded to give a dichot-
omous variable, brush teeth twice a day or
more do not brush teeth twice a day.
Explanatory variables
Childrens age (continuous variable) and ethnicity
(two categories: White and Other) were included as
explanatory variables in the models. Aside from
these, the variables included in the study as
potential predictors of twice-a-day toothbrushing
(or more) were related to the context of the family
and fell into four types: family demographics,
SES wealth, family relationships and mealtime
routines. For full details of survey questions and
optional responses for the majority of these vari-
ables see the HBSC Scotland National Report (32).
Family demographics
Family structure: Schoolchildren were asked about
the people they lived with in their main or only home,
where they lived all or most of the time. Respondents
were coded as living with both parents a single
parent step family other. Family size: Respondents
were asked how many brothers and sisters they had
living in their main or only home and were coded as
having no siblings one or two siblings more than
two siblings. Second home: Respondents were asked
about a second home or family they lived with, how
often they stayed there and the family members
living there. They were then coded as having a
second home not having a second home.
SES Wealth
Family Affluence Scale: The Family Affluence Scale
(FAS), used extensively with adolescents to measure
material affluence (33), was calculated from
responses to questions of car ownership, own
bedroom, family holidays and computer ownership,
combined using categorical principal components
analysis, as recommended (34), to produce tertiles of
low, medium and high family affluence. Family SES:
Young people were asked the occupation of their
mother and father, which were coded according to
the Registrar Generals social class classification.
Family SES, the higher of the two, was then re-coded
as high SES (SES 1, 2 or 3) low SES (SES 4 or 5).
Joblessness: Respondents were coded as having
neither parent working at least one parent working.
12
Family relationships
Contact with parents: When asked about the rela-
tionships with their mothers and fathers, young
people had an optional response category of Dont
have see. This was used to determine young
people who had a relationship with both parents
from those who had an absent parent with whom
they had no relationship. Perceived parenting: The
item from the KIDSCREEN-52 instrument (35)
which asked How often are you treated fairly by
your parents? was re-coded as treated fairly not
treated fairly. Relationship with parents: Young
people were asked how easy they found it to talk
to members of their family about things that really
bothered them. They were coded as having at least
one close relationship with their parents if they
found it easy to talk to at least one parent figure
(including step-parents). Relationship with elder
brother and elder sister: If they found it easy to talk
to their elder brother sister about things that really
bothered them, respondents were coded as having
a close relationship with their brother sister.
Mealtime routines
Breakfast: Young people were asked how often
they ate breakfast on weekdays. Responses were
re-coded as less than every weekday every week-
day. Family evening meal: Young people were asked
how many evenings per week they ate a meal with
their parents. Responses were re-coded as fewer
than four evenings per week four or more eve-
nings per week. Food poverty: Young people were
asked how often they went to bed hungry.
Responses were re-coded as sometimes (or more
often) go to bed hungry never go to bed hungry.
Data analysis
As there are known gender differences in twice-a-
day toothbrushing of young people (9, 36), the
dataset was stratified by gender and treated as two
separate datasets, one for girls and one for boys.
Preliminary analyses described the data, present-
ing frequencies for each variable, weighted by
school grade to ensure equal representation of age
groups in the samples for boys and girls. Gender
differences in prevalence rates were tested for
significance using chi-squared tests and results
discussed. Univariate logistic regression models
were fitted with the outcome variable of brushing
teeth twice a day or more brushing teeth less than
twice a day, using the statistical software SPSS,
version 15.0 Complex Samples package (SPSS Inc.,
Chicago, IL, USA). This took account of the

clustered nature of the data; children clustered
within schools, clustered within stratum, defined
by Education Authority and school type (indepen-
dent or state). Univariate models adjusted for one
explanatory family variable at a time and Odds
Ratios and 95% Confidence Intervals were calcu-
lated. Tests of independence between family con-
text explanatory variables were calculated and
discussed. To avoid multicollinearity, several mod-
els were made, including backward and forward
stepwise regressions, entering omitting the vari-
able explaining the largest smallest amount of
variance at each step, including only explanatory
variables in the univariate analyses with P < 0.15.
The best fitting multivariable models for boys and
girls were then presented establishing which of the
explanatory variables were most important in
predicting adolescent toothbrushing behaviour.
Two-way interaction terms between explanatory
variables were also fitted.
Results
Table 1 describes the child data that were analysed.
There were clear gender differences in toothbrush-
ing, with lower proportions of boys than girls
brushing their teeth twice a day or more. Boys were
significantly more likely to eat breakfast every
week day than girls, more likely to go to bed
hungry and more likely to perceive their parents as
treating them fairly. They were also more likely to
have contact with both their biological parents and
were more likely to be close to their elder brother,
but less likely to be close to their elder sister than
girls. Boys were also less likely to report living in a
second home, however, there were no gender
differences in family structure or family SES FAS.
There were generally greater missing data among
boys than girls; however, these did not rise above
10% for either, with the only exception being for
variable family SES which saw relatively high
missingness, as discussed by Currie et al. (33).
For this reason, all available data were included in
the separate univariate analyses.
Family affluence and family SES were signifi-
cantly associated with toothbrushing for both boys
and girls, with higher SES affluence associated
with greater odds of toothbrushing twice a day or
more (Table 2). Parenting perceived as fair was also
associated with higher odds of toothbrushing, as
was a close relationship with at least one parent for
both boys and girls. Eating breakfast and family
Toothbrushing in adolescence and the family
meals were associated with higher odds of tooth-
brushing among boys and girls and going to bed
hungry with lower odds. Age was significantly
associated with toothbrushing among girls only
and absence of a parent among boys only. The odds
of brushing teeth twice a day among boys in lone
parent families and girls in step families was
significantly lower than those from both parent
families.
When the family explanatory variables were
tested for independence, bivariate associations
(where those variables with 3 or more categories
were re-coded as dummy variables) showed cor-
relations for the most part ranging between )0.22
between high FAS and family SES 4 5, and 0.24
between perceived parenting and relationship with
parent(s), with the majority of correlations being
close to zero. Therefore, the strength of associa-
tions, although significant, was generally quite
small with the only exceptions being between
having a second home and living with both
parents, and having an absent parent and living
with both parents. Multicollinearity should there-
fore not be a concern. Nevertheless, several mod-
elling selection procedures were used in finding a
best-fit multivariable model.
Table 3 presents the final multivariable models
for boys and for girls. The variables shown were
found to be significant under both forward and
backward modelling procedures. Eating breakfast
was the best predictor of twice-a-day toothbrush-
ing among boys (log likelihood diff = 40.0) and
among girls (log likelihood diff = 39.2), with odds
of toothbrushing significantly greater for those who
ate breakfast on weekdays. The next best predictor
of boys toothbrushing was eating family meals
(log likelihood diff = 22.8) and of girls toothbrush-
ing, never going to bed hungry (log likelihood
diff = 22.0). FAS was the next best predictor for
both boys and girls (loglikelihood diff = 16.7 and
17.4, respectively), with greater odds of tooth-
brushing in high compared with low FAS, followed
by fair parenting and never going to be hungry
among boys, and age and a close relationship with
a parent among girls. Interaction terms between
these variables were not significant.
Discussion
The context of the family is known to be important
for a range of health and health behaviour outcomes
(37). Family characteristics such as relationships,
13
Levin & Currie

Table 1. The study population: sample size (n) and prevalence (%) of descriptive characteristics
Boys Missing Girls Missing
Sample size (n) 3063 3127
Toothbrushing (%)
Less than twice a day 35.4 0.9 20.5 0.5
Twice a day or more 64.6 79.5
Child demographics
Age (mean) 13.5 13.5 -
Ethnicity (%)
White 96.6 1.0 97.1 0.4
Other 3.4 2.9
Family demographics
Family structure (%)
Both parents 68.8 4.3 66.8 1.5
Step family 10.8 12.7
Lone parent 19.2 19.1
Other 1.1 1.4
No. siblings (%)
One or two 72.1 7.1 71.2 3.7
None 11.4 11.4
Three or more 16.5 17.5
Second home (%)
Do not have a second home 79.3 6.3 77.1 3.5
Have a second home 20.7 22.9
SES wealth
Family affluence (%)
Low FAS 32.8 4.7 34.3 2.8
Medium FAS 34.0 33.6
High FAS 33.2 32.1
Family SES (%)
High SES 66.8 22.6 67.5 18.6
Low SES 33.2 32.5
Parents in employment (%)
At least one parent working 94.9 6.5 95.0 4.2
No parents working 5.1 5.0
Family relationships
Contact with parents (%)
Have contact with both parents 89.3 3.3 86.8 2.1
Dont have see a parent 10.7 13.2
Perceived parenting (%)
Not treated fairly 17.6 1.2 21.0 0.9
Treated fairly 82.4 79.0
Relationship with parents (%)
Not close to any parent 15.6 3.6 15.4 1.7
Close relationship with at least one parent 84.4 84.6
Relationship with elder brother (%)
Not close to no elder brother 76.6 7.6 82.1 5.4
Close to elder brother 23.4 17.9
Relationship with elder sister (%)
Not close to no elder sister 75.6 9.0 72.0 6.2
Close to elder sister 24.4 28.0
Mealtime routines
Breakfast (%)
Less than every week day 33.0 1.6 42.3 0.9
Every week day 67.0 57.7
Family evening meal (%)
Fewer than 4 evenings per week 29.2 2.2 27.3 1.6
Four or more evenings per week 70.8 72.7
Food poverty (%)
Do not go to bed hungry 73.8 0.7 76.1 0.3
Go to bed hungry sometimes 26.2 23.9
Variables were weighted by grade to ensure equal representation.

14
 Toothbrushing in adolescence and the family

Table 2. Univariate logistic regression analyses of the associations between child and family characteristics and twice-a-
day toothbrushing
Boys Girls
OR 95% CI OR 95% CI
Child demographics
Age 0.99 (0.941.04) 1.05 (0.991.11)
Ethnicity
White 1 1
Other 0.83 (0.561.23) 0.77 (0.501.19)
Family demographics
Family structure
Both parents 1 1
Step family 0.90 (0.721.12) 0.76 (0.570.99)
Lone parent 0.72 (0.600.85) 0.93 (0.751.16)
Other 0.60 (0.301.23) 1.38 (0.633.03)
No. Siblings
One or two 1 1
None 1.05 (0.811.37) 0.86 (0.641.14)
Three or more 0.83 (0.681.01) 0.90 (0.711.13)
Second home
Do not have a second home 1 1
Have a second home 0.94 (0.771.15) 0.88 (0.711.09)
SES wealth
Family affluence
Low FAS 1 1
Medium FAS 1.37 (1.151.63) 1.50 (1.251.80)
High FAS 1.56 (1.271.92) 1.56 (1.251.95)
Family SES
High SES 1 1
Low SES 0.84 (0.720.98) 0.78 (0.650.93)
Parents in employment
At least one parents working 1 1
No parents working 0.67 (0.470.93) 0.72 (0.501.02)
Family relationships
Contact with parents
Have contact with both parents 1 1
Dont have see a parent 0.76 (0.600.96) 0.91 (0.711.16)
Perceived parenting
Not treated fairly 1 1
Treated fairly 1.45 (1.221.73) 1.40 (1.131.73)
Relationship with parents
Not close to any parent figures 1 1
Close relationship with at least one parent 1.50 (1.211.84) 1.52 (1.221.90)
Relationship with elder brother
Not close to no elder brother 1 1
Close to elder brother 1.10 (0.921.31) 1.16 (0.911.48)
Relationship with elder sister
Not close to no elder sister 1 1
Close to elder sister 1.09 (0.921.29) 1.09 (0.901.33)
Mealtime routines
Breakfast
Less than every week day 1 1
Every week day 1.69 (1.471.93) 1.84 (1.572.16)
Family evening meal
Fewer than 4 evening per week 1 1
Four or more evenings per week 1.60 (1.381.85) 1.21 (1.001.46)
Food poverty
Never go to bed hungry 1 1
Go to bed hungry sometimes 0.68 (0.580.80) 0.57 (0.460.70)
Variables with ORs and CIs in bold font were included in multivariable analyses.

15
Levin & Currie
Table 3. The final multivariable logistic regression analysis of the association between child and family characteristics
and twice-a-day toothbrushing
Age
Family affluence
Low FAS
Medium FAS
High FAS
Perceived parenting
Not treated fairly
Treated fairly
Relationship with parents
Not close to any parent figures
Close relationship with at least one parent
Breakfast
Less than every week day
Every week day
Family evening meal
Fewer than 4 evening per week
Four or more evenings per week
Food poverty
Never go to bed hungry
Go to bed hungry sometimes
parental control and support, family values and
culture are associated with young peoples health
and health behaviour, and health in adulthood (38,
39). The role of rituals and routines within the family
has also been studied in association with the health
of young people (28). In particular, it has been shown
that rituals and routines are important for the
psychological health of all members of the family.
Young people therefore not only benefit directly, but
also indirectly through the health and well-being of
their parents.
Family rituals and routines have also been
associated with lower risk behaviour such as
alcohol consumption among offspring (40). The
common risk factor approach (41) suggests that the
existence of family routines may be beneficial in
terms of all risk and health promoting behaviours.
For toothbrushing, however, this may be especially
true as, unlike many behaviours, oral health care is
carried out almost exclusively in the home, usually
before going to bed and on waking. Furthermore,
toothbrushing behaviour is formed at an early age
(7, 8), when parental socialization is particularly
influential.
Mealtime routines, such as sharing a family meal
may improve oral health in a number of ways.
First, mealtime routines are likely to reduce snack-
ing and the consumption of sugary food, which
are known to be associated with caries (2, 17, 42).
Secondly, mealtime routines are likely to pro-
vide better nutrition which is good for physical
16
Boys Girls
OR 95% CI OR 95% CI
1.08 (1.021.15)
1 1
1.30 (1.081.57) 1.48 (1.221.79)
1.46 (1.181.82) 1.44 (1.151.80)
1
1.30 (1.071.58)
1
1.36 (1.071.72)
1 1
1.54 (1.331.79) 1.79 (1.482.15)
1
1.45 (1.251.70)
1 1
0.79 (0.660.93) 0.64 (0.510.80)
development and overall health, including oral
health (42). The third way in which mealtime
routines may improve oral health is shown in the
current study, indirectly, through increased rates of
toothbrushing. Family meals encourage positive
relationships and communication between family
members, reinforcing parental roles, a stronger
family identity and socialization of young people.
Family meals also help to create a routine, whereby
young people have structure in their day. Tooth-
brushing of itself is a routine. By creating structure
in the day, one routine (such as mealtime) is likely
to reinforce a second (toothbrushing).
This study found that when all variables were
considered simultaneously, the best predictor of
twice-a-day toothbrushing for both boys and girls
was eating breakfast. Eating a family evening meal
four or more times per week had an additive effect
among boys, while going to bed hungry was
negatively associated with toothbrushing for both
boys and girls. The association between family
structure and toothbrushing disappeared after the
addition of family relationship and mealtime
routine variables. However, the association with
family affluence remained for both boys and girls.
Socioeconomic inequalities in toothbrushing
therefore persist even after relationship and eating
routine variables are added. Adolescents from
higher affluence families may be more likely to be
born and raised in a safer environment, promoting
health behaviours, including oral health. Affluent

families attend dental services more often (36) and
may therefore have the importance of oral hygiene
reinforced in a way that less affluent nonattendees
do not. Pia Christensens claim that families can be
health promoting regardless of SES (39), however, is
evident in the current study, as the positive additive
effect of eating breakfast and, in the case of boys,
evening meals, is seen among young people from
both high and low affluence families. Given the
many benefits of family routines and rituals previ-
ously discussed, of all possible family activities, e.g.
holidays, family trips or sporting activities, sharing a
meal is one of the least expensive and in fact may be
less expensive than the alternative everyone
having their own separate meal because of econ-
omies of scale. It should therefore be relatively easily
to adopt by both affluent and deprived families, with
economic and well as nutritional, psychological and
other health benefits.
Limitations
No information was available on parental tooth-
brushing or toothbrushing behaviour of older
siblings. As toothbrushing behaviour in offspring
may be adopted through parental modelling, it is
recommended that similar future studies include
this information. As this study was cross-sectional,
we cannot make assertions on the direction of
association; however, it is unlikely that not brush-
ing teeth would result in a child not eating
breakfast. The relationship may nevertheless be
indirect and due to a common factor unaccounted
for in the current analysis. Quantitative methods in
general, although statistically robust, are therefore
limited to the variables included in the study.
Although findings from the current study are
generalisable to the Scottish adolescent population
and show strong associations between family
meals and relationships and twice-a-day tooth-
brushing, to fully understand the complex inter-
relationships between the complete range of factors
in varying home environments, future work should
involve qualitative techniques.
Conclusions
Family relationships and the home environment
have received little attention relative to family
structure and family wealth SES in the oral health
literature. However, mealtime routines and posi-
tive parentchild relationships are highly associ-
ated with prevalence of twice-a-day toothbrushing,
Toothbrushing in adolescence and the family
and are of particular interest as, unlike attaining
higher affluence, they may be relatively easily
achieved. This suggests that the family and home
environment should play a central role in the
promotion of oral health, through mealtime rou-
tines, incorporating a fair parenting style and
developing open and positive family relationships.
Acknowledgements
The Health Behaviour in School-aged Children (HBSC)
study is an international survey conducted in collabora-
tion with the WHO Regional Office for Europe. The
authors would like to acknowledge the HBSC inter-
national research network in 43 countries that developed
the studys research protocol. This study was funded by
NHS Health Scotland.
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