The Effectiveness of E-Learning Anticipatory Guidance on Early Childhood Caries among the Mothers of Children Aged 9–24 Months during the Pandemic: A Nonrandomized Controlled Trial
ntroduction Early childhood caries (ECC) refers to any primary tooth in a preschool-aged child who is 71 months of age or younger that has one or more decayed (cavitated or noncavitated lesions), missing (due to caries), or filled surfaces (AAPD, 2005). Other names include nursing bottle caries, night bottle mouth, nocturnal bottle caries, maternally derived streptococcal mutans disease, and infant bottle tooth decay syndrome. Early after they erupt in the oral cavity, nearly all milk teeth are affected by the common illness ECC. About 49.6% of children in India between the ages of 8 and 48 months have this condition (Muthu et al., 2017; Simratvir 2009; Bhayade 2016; Chawla 2006; Dash 2002). Children aged 0 to 3 in rural south India were found to have a prevalence of ECC of 40.6%, with cavitated surfaces in 49.7% and noncavitated surfaces in 50.3% of cases (Henry et al., 2017). Initial primary incisor caries before the age of four discourages the development of subsequent dental caries lesions (Al Shala, 1997). The pathognomonic aspect of this disease is that it has a regular etiology and even a conventional progression pattern, making it simple to detect, treat, and ultimately avoid. If neglected, it may result in complications such as malnutrition and anemia due to difficulties eating, speech issues, and malocclusion from early tooth loss. The child develops an aversion to dentistry as a result of the pain and anxiety of the procedures, which prevents the pediatric dentist from using many behavior management techniques to control the child's anxiety, as he reacts in a fight-or-flight manner to the pain of injections and cellulitis. The permanent dentition and additional teeth both become affected by ECC, in addition to these psychological issues brought on by bullying and peer pressure as a result of the child being isolated and ignored. , The coronavirus disease (COVID) times have made personal visits to the clinic more of a threat to the mother and child, so prevention becomes imperative. ECC is a devastating disease of the teeth that can lead to life-threatening aftermath if not treated in time. It can be very crippling to neglect it, so anticipatory guidance can be very practical in motivating mothers to avoid the known etiologic factors, such as the wrong practice of feeding milk, along with other factors. ECC affects both additional teeth and the permanent dentition, together with these psychological problems brought on by bullying and peer pressure as a result of the child being excluded and ignored. The study aims to assess the effectiveness of online anticipatory guidance. During this pandemic, most parents fear bringing their child to the clinic; hence, the need for this study is to improve awareness through anticipatory guidance among parents of children aged 9–24 months ( ). 

aterials and M ethods Ethical Review The Institutional Ethics Committee of KVG Dental College and Hospital approved this study (Ref. no.: IECKVGDCH/SS15/2020–21). All participants were provided with a consent form. Study Design This study manuscript follows and is reported by the TREND criteria for nonrandomized clinical trials. This is a pretest and posttest nonrandomized clinical trial. One example of an approach is the addition of contacts to online communities. Snowball sampling is therefore used after the study. The number of participants may range from 50 to 200, as it is a duration-based study, but only those who are willing and meet the inclusion and exclusion criteria are chosen for the study. Inclusion Criteria Children with erupted upper incisor teeth, mothers whose child is between the ages of 9 and 24 months, and consenting participants are all included in this study. Exclusion Criteria Children who have severe systemic diseases, such as bleeding disorders, cardiac disorders, or renal disorders, are taking long-term antiepileptic medications, have oral soft tissue lesions, a history of allergies to the ingredients in fluoride gel, are ill overall, or need prolonged rehabilitation were excluded. All study materials, including a consent form, a self-completed questionnaire, and information regarding oral health awareness, were provided to the participants. The parent/caregiver and child were assessed using “Lift the Lip,” an oral health assessment tool for use on babies and young children. Parents received pamphlets with instructions on how to perform the “Lift the Lip” technique in advance. The front anterior teeth, in particular, need to be visually inspected in order to identify extremely early signs of dental decay, such as white spot lesions. It is easy to complete and doesn't require a dental professional. ”Lift the Lip” aims to educate parents and guardians about oral health and promote their involvement in clinical dentistry treatments. Parents are also encouraged to regularly check their children's teeth at home. The use of “Lift the Lip” highlights the importance of dental services and child health specialists having solid training and working together. Using a smartphone camera with at least 2 megapixels of resolution and adequate lighting, children were evaluated for this study. Mothers received training on how to take a standard photo. Additionally, the online image acquired through the caries risk assessment tool was used to categorize the lesion ( ). The self-completed questionnaire collected sociodemographic information (age, sex, education level, family income, Aboriginality) and knowledge of children's oral hygiene from mothers. The impact of the awareness was assessed using the self-structured, validated questionnaire. Participants were given this questionnaire both at baseline and 6 months later ( https://docs.google.com/forms/d/e/1FAIpQLSe_1kkGWqKOA2auFSUWdS9Pw_B69hEP1mBRr94Xfh4-Hu5ZiQ/viewform?usp=sf_link ). A total of thirty-two closed-ended items measuring five Likert scales constitute the questionnaire. Using statistical power analysis with G*Power 3 software and considering goodness of fit test analysis, the sample size for the current study was estimated to be 197 by maintaining α error as 0.05 at a 95% confidence interval, β error as 0.2, power of the test (1-β error) as 80%, effect size (Cohen's w) as 0.20 (Manchanda et al., 2014), and degrees of freedom as 1. The final target sample size was increased to 200 to allow for unanticipated deviations from statistical assumptions, specifically for the evaluation of a single group of dyads (mother/one parent and child). A pre- and postquestionnaire was given within the same group. Thirty parents participated in the pilot study, which was conducted to assess the study's validity and reliability. The 30 participants received the questionnaire and were asked to rate their level of comprehension or reading ability. While validating, the Flesch-Kincaid readability score was 50.8, the Flesch-Kincaid grade level was 9.8, and Aiken's V index for each item ranged from 0.75 to 1 (high to very high). Additionally, face validity was analyzed separately. The Cronbach's alpha test, used to assess the study's reliability, yielded an acceptable result of 0.83. Traditional awareness techniques, such as presentations, video models, and posters, were used to raise awareness among mother-child dyads. Oral screening and evaluation were then conducted at the time of follow-up to see if the white spot lesions had reversed. The final posttest questionnaire was distributed at the end of 6 months, and a final oral screening and evaluation were carried out. Following this, the information was gathered, evaluated, and combined to yield the final results. The study design provides much clarification of the study . 

The Institutional Ethics Committee of KVG Dental College and Hospital approved this study (Ref. no.: IECKVGDCH/SS15/2020–21). All participants were provided with a consent form. 

This study manuscript follows and is reported by the TREND criteria for nonrandomized clinical trials. This is a pretest and posttest nonrandomized clinical trial. One example of an approach is the addition of contacts to online communities. Snowball sampling is therefore used after the study. The number of participants may range from 50 to 200, as it is a duration-based study, but only those who are willing and meet the inclusion and exclusion criteria are chosen for the study. 

Children with erupted upper incisor teeth, mothers whose child is between the ages of 9 and 24 months, and consenting participants are all included in this study. 

Children who have severe systemic diseases, such as bleeding disorders, cardiac disorders, or renal disorders, are taking long-term antiepileptic medications, have oral soft tissue lesions, a history of allergies to the ingredients in fluoride gel, are ill overall, or need prolonged rehabilitation were excluded. All study materials, including a consent form, a self-completed questionnaire, and information regarding oral health awareness, were provided to the participants. The parent/caregiver and child were assessed using “Lift the Lip,” an oral health assessment tool for use on babies and young children. Parents received pamphlets with instructions on how to perform the “Lift the Lip” technique in advance. The front anterior teeth, in particular, need to be visually inspected in order to identify extremely early signs of dental decay, such as white spot lesions. It is easy to complete and doesn't require a dental professional. ”Lift the Lip” aims to educate parents and guardians about oral health and promote their involvement in clinical dentistry treatments. Parents are also encouraged to regularly check their children's teeth at home. The use of “Lift the Lip” highlights the importance of dental services and child health specialists having solid training and working together. Using a smartphone camera with at least 2 megapixels of resolution and adequate lighting, children were evaluated for this study. Mothers received training on how to take a standard photo. Additionally, the online image acquired through the caries risk assessment tool was used to categorize the lesion ( ). The self-completed questionnaire collected sociodemographic information (age, sex, education level, family income, Aboriginality) and knowledge of children's oral hygiene from mothers. The impact of the awareness was assessed using the self-structured, validated questionnaire. Participants were given this questionnaire both at baseline and 6 months later ( https://docs.google.com/forms/d/e/1FAIpQLSe_1kkGWqKOA2auFSUWdS9Pw_B69hEP1mBRr94Xfh4-Hu5ZiQ/viewform?usp=sf_link ). A total of thirty-two closed-ended items measuring five Likert scales constitute the questionnaire. Using statistical power analysis with G*Power 3 software and considering goodness of fit test analysis, the sample size for the current study was estimated to be 197 by maintaining α error as 0.05 at a 95% confidence interval, β error as 0.2, power of the test (1-β error) as 80%, effect size (Cohen's w) as 0.20 (Manchanda et al., 2014), and degrees of freedom as 1. The final target sample size was increased to 200 to allow for unanticipated deviations from statistical assumptions, specifically for the evaluation of a single group of dyads (mother/one parent and child). A pre- and postquestionnaire was given within the same group. Thirty parents participated in the pilot study, which was conducted to assess the study's validity and reliability. The 30 participants received the questionnaire and were asked to rate their level of comprehension or reading ability. While validating, the Flesch-Kincaid readability score was 50.8, the Flesch-Kincaid grade level was 9.8, and Aiken's V index for each item ranged from 0.75 to 1 (high to very high). Additionally, face validity was analyzed separately. The Cronbach's alpha test, used to assess the study's reliability, yielded an acceptable result of 0.83. Traditional awareness techniques, such as presentations, video models, and posters, were used to raise awareness among mother-child dyads. Oral screening and evaluation were then conducted at the time of follow-up to see if the white spot lesions had reversed. The final posttest questionnaire was distributed at the end of 6 months, and a final oral screening and evaluation were carried out. Following this, the information was gathered, evaluated, and combined to yield the final results. The study design provides much clarification of the study . 

esults To assess the knowledge and attitude of the mothers toward ECC, scoring was given as poor and good ( ). The pretest and posttest showed a substantial change at baseline. By the end of 6 months, the mothers’ knowledge of ECC had risen from approximately 28.5% to nearly 81% after the interview ( ). Since the attitude nearly provides identical sampling variability and has no effect on the behavior of the children, it is marginally significant ( ). Although 90% of mothers agreed that they would frequently notice any changes in their child's mouth during the practices, 100% of mothers recommended the lift-the-lip procedure once a week, along with the first dental appointment as soon as the tooth erupts. Additionally, 86% recommended it for nutritional and preventive health, and 16.5% recommended brushing and flossing as the best way to prevent ECC ( and ). 

iscussion It is preferable to begin ECC prevention in the prenatal and perinatal periods very early. The risk of passing these germs to newborns whose mothers have greater levels of Streptococcus mutans due to untreated dental caries is higher. Numerous studies have shown that when S. mutans bacteria are acquired early in life, they primarily result in ECC. Other factors, such as race, socioeconomic status of the caregivers, water fluoridation, number of years of education, and dental insurance coverage, may contribute to the development or prevention of caries. , It is believed that children with a history of dental caries, as well as those whose parents and siblings have severe dental caries, are more likely to experience dental caries themselves in the future. , Additionally, children's involvement in the financial burden influences adults’ dental well-being. Adults’ oral health is impacted by a number of variables, including limited access to dental care and insufficient availability of preventive treatments, including fluoridated water, fluoride toothpaste, and fluoride varnish. According to studies, there are two ways for S. mutans to be transmitted: vertically and horizontally. Parent-to-child vertical transmission occurs when a mother or father is the caregiver. Therefore, having poor dental hygiene and consuming more sugar each day increases the likelihood that the mother may pass the infection on to her child. On the other hand, neonatal variables may raise the risk of contracting S. mutans in cases of horizontal transmission. S. mutans is transmitted more quickly by cesarean delivery than by vaginal delivery. Between S. mutans colonization and the beginning and progression of caries lesions, it takes around 13–16 months. Young children are more likely to experience enamel demineralization if they are fed at night using nursing bottles or sippy cups. Drinking sugary drinks at night should be avoided or at least reduced because of the increased risk of dental caries caused by the flow of saliva and oral clearance during the night. The main objective of oral health education is to foster essential leadership for oral health reviews and to encourage sensible decisions for such practices. The ultimate goal of oral health education is to prevent disease. The substrate component of sugar is the key factor causing caries to occur. As a result, the majority of dentists have shifted their focus to educating parents and caregivers about altering children's diets and feeding patterns. , In order to reduce the condition, healthcare professionals such as doctors and nurses play a vital role in teaching both parents and children. Most kids don't go to the dentist until they are 3 years old. By providing information in the form of pamphlets, experiences, or learning exercises intended to promote oral care, oral health education can be carried out. The optimum strategy for newborn oral health care is the early formation of a dental home, which includes ECC prevention and management. , The acceptance of the age-one dental visit can be facilitated by including oral health education in the curricula of medical, dental, nursing, and allied health professional programs. , Predictive advice to lower the risk of dental caries should include diet analysis, counseling to limit consumption of sugar-containing beverages, and advice on cleaning children's teeth twice daily with the proper amount of fluoride toothpaste. To ensure knowledge of age-specific oral health issues, the AAPD encourages collaboration with early intervention programs, schools, early childhood education and care programs, members of the medical and dental communities, and other public and private community agencies. According to Lin et al.'s study, improvements in oral health knowledge and good tooth-cleaning habits were seen after a dental public health program, which is consistent with our study's findings. In this study, a comparison of the data from the beginning and the end revealed a significant difference in the growth in knowledge and attitude levels in the group receiving direct intervention, suggesting that the educational program had a good impact when it was delivered in this manner. Cardenas and Damon observed that the tested population's awareness of oral health increased within four weeks of receiving anticipatory counseling through a PowerPoint presentation, which is similar to the results of the current study. The direct and indirect intervention groups significantly differed from one another and the control group, demonstrating the direct intervention's beneficial impact on modifying the knowledge of the expectant mothers. Bahri et al. found that the knowledge scores obtained by the control and intervention groups at the end of their study differed significantly, which is consistent with the findings of the current study. However, our study is one of the few that looked at instructional strategies for providing guidance to mothers of children between the ages of 9 and 24 months during the epidemic. Given the limitations, it is recommended that research be conducted to assess the long-term progression of changes in variables. The outcomes of different oral health care teaching strategies can be investigated in such a study. 

onclusion In conclusion, enhancing the experience of the caregiver with caries and her perception of the child's oral health condition may improve the experience of the child with caries and the family's quality of life with regard to oral health. These facts are significant and ought to guide public oral health initiatives for children. Limitations The complicated interaction of numerous components in the current picture of ECC makes it impossible for this investigation to pinpoint the precise cause of ECC. To reveal the hidden components of this aspect, more investigation is required. 

The complicated interaction of numerous components in the current picture of ECC makes it impossible for this investigation to pinpoint the precise cause of ECC. To reveal the hidden components of this aspect, more investigation is required. 

