Despite attention paid to parental refusal of child vaccines, the phenomenon of topical fluoride refusal is poorly understood. We examine the extent to which parent attitudes and Internet use regarding topical fluoride treatment and vaccines may overlap and, in turn, uniquely or distinctly correlate with fluoride and vaccine refusal for the child. In 2017, we analyzed data collected from 2011 to 12 for 361 children from three Washington state dental clinics. The instrument included analogous measures of topical fluoride and vaccine safety concerns, perceived severity of preventable cavities/disease, and Internet use for fluoride/vaccine information; and measures of non-fluoridated toothpaste use, attitudes towards dental x-rays and amalgam and composite fillings. We assessed dental chart-based topical fluoride refusal occurring in 2009 or 2010 and parent-reported vaccine refusal. All analogous fluoride and vaccine items were substantively correlated. However, in a series of adjusted models, none of these items were significantly associated with fluoride refusal. Multiple fluoride and vaccine items were associated with vaccine refusal in unadjusted models; but only vaccine safety concerns, perceived severity of a preventable cavity, and Internet use for vaccine information remained significant in adjusted models. Although there is concordance between the two refusal behaviors as well as analogous attitudes and Internet use, these findings challenge the idea that fluoride refusal should be addressed with interventions focusing on vaccine refusal. Further research is required on the factors underlying refusal of preventive dental care.
In identifying how fluoride- and vaccine-related attitudes and behaviors overlap, but are associated with vaccine—but not fluoride—refusal, our study highlights the need for specialized research on the complex behavioral and social factors associated with refusal of preventive dental care. First, there is a need for detailed qualitative research to better understand why caregivers refuse various types of preventive care. Once the reasons are known, interventions tailored to specific reasons for refusal can be developed and refined. The eventual goal is to develop chairside screening tools that clinicians can use to identify caregivers who are likely to refuse and diagnostic tools that specify the reasons for refusal. These tools will then enable trained clinicians to intervene chairside with tailored approaches.
Furthermore, to the extent that fluoride and vaccine attitudes and Internet information-seeking are correlated (and non-fluoride toothpaste associated with fluoride refusal), it is necessary to further delineate the extent to which attitudes, behaviors, and refusal for topical fluoride, vaccinations, and other preventive treatments represent (a) isolated choices and behaviors, (b) a general risk calculus regarding benefits versus harms, or (c) a more latent health lifestyle composed of various parenting attitudes (Reich, 2016). Community and network-focused studies may help inform these questions given identified community clustering of vaccine refusal (Lieu et al., 2015).
Like vaccine refusal, much work remains in identifying factors that motivate fluoride refusal—to reduce the risk of caries and associated oral and other diseases and promote improved parental and general public understanding of the benefits of preventive treatments.
This study was supported by the National Institute of Dental and Craniofacial Research of the National Institutes of Health (grants K08DE020856, L60MD003921, R03DE021439, and U54DE019346), the University of Washington Institute for Translational Health Sciences (grant UL1RR025014), the William T. Grant Foundation Scholars Program, and the Center for Advanced Study in the Behavioral Sciences (CASBS) at Stanford University. RMC received fellowship funding from the Killam Trusts while conducting this research. None of these funders had any role in the study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.