Level of Knowledge And Attitude Of Mothers Through Health Awareness Programs Towards Nursing Bottle Caries: A Cross Sectional Study At Al-karkh Primary Health Care Sector .

Introduction: Tooth decay in infants and toddlers is often referred to as Nursing Bottle Caries(NBC),and as a comprehensive address, referred to Early Childhood Caries(ECC), Children need strong, healthy teeth to chew their food, speak and have a good-looking smile, also it is important for their general health,The role of mothers in avoiding children with nursing Bottle caries is a large and fundamental ,mothersorientations and knowledge , is essential to reduce the percentage of children with tooth decay, developed countries are concerned with awareness and health education programs as a first step in achieving a healthy and disease-free society. Objective: the purpose of this study was:


Introduction
Dental caries is a multifactorial disease that starts with microbiological shifts within the complex biofilm and is affected by salivary flow and composition, exposure to fluoride, consumption of dietary sugars, etc, 1 Caries in infants and young children which referred to (Early childhood caries ECC ) has long been recognized as a clinical syndrome, described by Belterami,² in 1930s as "Les dents noire de tout-petits" which means "black teeth of the very young." is perhaps the most popular in this perspective for defining the term "nursing bottle mouth",³as in Fig( 1).

Fig(1) early childhood caries
Subsequently, other terms such as "baby bottle tooth decay", "nursing bottle syndrome", "bottle mouth caries", "nursing caries", "rampant caries", "nursing bottle mouth", "milk bottle syndrome", "breast milk tooth decay" and "facio-lingual pattern of decay" have also been used to describe this condition 4. The prevalence and severity level of caries in children aged under 5-yr-old in several countries are quite high and have showed tendency to increase,and the prevalence of NBC also varies widely with several factors like race, culture, and ethnicity; socioeconomic status, life style, dietary pattern, and oral hygiene practices and also according to the various factors from country to country and from area to area,A review of the literature suggests that in most developed countries the prevalence rate of NBC is between 1 and 12% ,In less developed countries and among the disadvantaged groups in the developed countries, the prevalence has been reported to be as high as 70%, NBC has been found to be more prevalent in low socioeconomic groups 5.It is widely accepted that the group of cariogenic microorganisms, streptococcus mutans, is associated with NBC, children with NBC reportedly have elevated oral levels of streptococcus mutanswhich combine with frequent carbohydrate intake to produce abundant acid that lowers plaque pH for extended periods and demineralizes the child's teeth 6 , many studies show that Nursing caries is a form of tooth decay that is caused by children sleeping with bottles.This is also called baby bottle or nursing bottle tooth decay,the main cause is when a child goes to bed with a bottle filled with milk or juice--anything except waterFig(2),It usually affects children between the ages of one and two years, Breastfeed infants who fall asleep while breastfeeding are also at risk 7 .

Fig(2) teeth decay due to bottle feeding on bed
In general, dental caries is a preventable disease process, However, when preventive regimens are not applied and the disease goes untreated, extensively decayed teeth of very young children are not easily restored in a dental office,Over 70 years of research have demonstrated the use of fluorides is the most effective means for preventing or arresting caries, 8 As well as through the health food free of carbohydrates and periodic review of the dentist and cleaning the teeth properly and this requires the knowledge of parents of the risk of exposure the teeth of their children under the age of five years old to the decay, as the initial follow-up of the child starts from parents , also Breast feeding is important for the health of child's teeth,Fig ( 3) which show that Early childhood caries preventive strategies should begin with prenatal education of expectant parent(s), progress through the perinatal period, and continue with the mother and infant , 9 .3) Strategies for theprevention of early childhood caries at various levels. 9e World Health Organization (WHO) Global Oral Health Program has worked hard over therecent years to increase the awareness of oral health worldwide as oral health is important component of general health and quality of life.Meanwhile, oral disease is still a major public health problem in high income countries and the burden of oral disease is growing in many low-and middle income countries 10 ,

METHODS
The study was conducted atthe primary health care centers which were 9 centers in al karkh primary health care sector in Baghdad from, February 2017 -April 2017, all the mothers fulfilling the following inclusion criteria participated in the study, the inclusion criteria included; no medical condition in their children and the child's age under age of 5 years, A questionnaire modified from that used by Scroth et al (2007), 11,12,13 was prepared in Arabic to collect information about mothers's oral health knowledge and actions towards oral health of their preschool children,the statements from 1-2 represents the The role of governmental institutions related to in dissemination of health awareness, the statements from 3-11representknowledge of mothers, and from 12-18 represents the attitude, the answers to the statements were to determine their knowledge about the importance of the safety of children teeth under the age of five and their precautionary measures to maintain them.The questionnaire was pre-tested and appropriate changes were incorporated to make all the statements comprehensible for the mothers, the mothers had the choice to agree or disagree and I don't know with the statements.In addition to, A total of 85 questionnaires were distributed selected (85) mothers whom their Educational level status (ELS) as in table (1), completed forms were received back as summarized in Table (2), the data was analyzed using SPSS software version 11.0.:  14 Maternal attitude towards oral health is significantly correlated to the oral health of their children, 15 the assessment of knowledge, attitude among mothers of children under 5 years old can indicate knowledge areas that are lacking and approaches and practices that are flawed,Through the field follow-up of health center records, it was found that 37% of children under the age of five enrolled in MCH ( mother and child health program ) records suffer from NBC. 16 In the present study the opinion about Problems with baby teeth will affect child's permanent teeth, 27% agree, 35% disagree, 38% don't know,This suggests a lack of knowledge about the relationship between primary and permanent teeth,Lactic teeth are considered as a determinant of the pathway of permanent tooth eruption as well as a major factor in the growth of the jaw,A majority of 52% did not have any view about teeth decay and its effect on child's general health,18% agree and 30% disagree, so there is a lack of knowledge of the content of the term despite the level of study in the sample research,Oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialize, as well as their feelings of social wellbeing, 17 in study byAcs.Et.al, children of three years of age with nursing caries weighed about 1 kg less than control children, because toothache and infection alter eating and sleeping habits, dietary intake and metabolic processes, Disturbed sleep affects glucosteroid production 18 .20% agree that baby teeth are important for child's general health,%19 disagree and %57 with no response, As it is clear that weak knowledge of the importance of teeth children take the largest proportion of answers, 12% agree that public health awareness programs emphasize the seriousness of early childhood caries,%71 disagree and %15 did not know also about the next statement community health awareness is important to prevent disease %78 agree,%12 disagree and18% did not know,Through the answers on the two statements above it is clear that there was no health awareness for most mothers the study sample by their different levels of study, health ministries and health authorities are responsible for health awareness, and as one of the definitionsof health : health is an information process aimed at adopting a healthy and healthy lifestyle, and helping people improve their behavior by influencing their beliefs and attitudes, not only at the individual but also at the community level, health education raising health awareness by providing individuals with information and experiences In order to influence their attitudes, knowledge, health behavior and community, health education is a set of activities aimed at raising health knowledge and instilling healthy behaviors in individuals and communities, 19 regarding the nutrition of the mother during pregnancy and its importance to the teeth of the child, 34% of the supporters of the content of the term, but we still lack good knowledge through the proportion of 21% who did not agree with the statement and 45% who have no opinion, The juices, which are said to be natural and are used by parents along with breast milk in the early years of the baby's life, contain more sugar than soda, meaning that they exceed the global recommendations for the amount of carbohydrates that the child is allowed to eat, The problem is that the baby takes these juices through the bottle, and therefore spends much longer than the older person needs to drink the same quantity with the cup, so the baby's teeth are exposed to the sugar for a long time and thus becomeProne to decay, 20 71% of the mothers, despite the multiple level of education answered in agreement with that the juice does not harm the teeth, which indicates the weakness of knowledge of the components of the juice of sugar and its effect on the teeth of children,47% of the mothers agreed that breastfeeding the child during the night or during the period of sleep the child does not hurt the teeth of the child and at the same time 35% did not have an answer,although breastfeeding provides the ideal nutrition for infants, and there are a number of health benefits to the breastfed child, including reduced risk for gastrointestinal and respiratory infections, butprolonged, unrestricted and night time breastfeeding, however many studies have been reported to be potential risk factors for the development of ECC, frequent and prolonged contact of enamel with human milk has been shown to result in acidogenic conditions and softening of enamel, 21 with the statements 9-10-11 as in table (2) The idea of artificial breast feeding for children during sleep is so as not to wake up because of hunger at night, although there is an awareness about synthetic milk damage in generalas in statement (9) with which 66% of the mothers agreed,but 44% agreed that using bottle feeding on bed of no hurt to the teeth and 35% don't know , 34% agreed that bottle feeding the child after 12 months of age is harmful for his/her teeth but 49% had no thought and the remaining 16% disagree, this means that there is no knowledge of bottle feeding effect on children's teeth specifically .With regard to the statements concerning the procedures of mothers to keep the teeth of children and protect them from (NBC(, there was no agreement by mothers to clean the child's mouth before the growth of the teeththrough the 53% as they answered (don't know) and 32% who did not agree, cleaning the child's mouth by the mother should begin before the teeth grow as a beginning to maintain the teeth and will continue after the growth of the teeth, 22 current drinking water recommendations are 0.6ppm of fluorideto prevent dental caries, It's this concentration that provides a balance of reducing dental caries while minimizing the risk of dental fluorosis, 23 The use of fluoride is not limited to obtaining it from drinking water, but can be used through the toothpaste containing fluoride, children's deciduous teeth be brushed twice per day with a tiny smear of fluoride toothpaste as soon as they erupt, 24 A good percentage of mothers 74% agreed that breastfeeding is necessary for child health This concept of health is widely recognized and may have been gained from parents or even colleagues at work, because there is a good health awareness about this subject, Most mothers use bottle feeding as a mean to prevent a child from crying or consider bottle feeding as the best solution for crying.The current study shows that 29% agreed that breastfeeding is the best solution for crying and 53% have no answer.It is a hesitation because they do not have adequate health information,17% agreed thatChildren should see a dentist when the first tooth erupts in the mouth while 24% disagree and 59% don't know, According to the American Academy of Pediatric Dentistry (AAPD), children should visit us by their first birthday.It is important that your child's newly-erupted teeth (erupting at 6-12 months of age) receive proper dental care and benefit from proper oral hygiene habits right from the beginning.. 25 As shown in Table 2 it is clear that 59% of mothers had no information about the importance of the first visit to the dentist while at the same time 24% did not agree with that children should see a dentist by their first birthday, with the last statement which said that Children should see a dentist only when they have a dental problem,early childhood oral health influences and outcomes are considered pivotal in determining oral health trajectories across the life course, and can impact oral health and disease occurrence in adulthood, 26 early childhood caries, the most common chronic childhood disease, preventive dental care for children younger than 2 years by primary care professionals, reduces subsequent need for fillings and other treatments for tooth decay as The American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that risk assessment and preventive care should begin with the eruption of the first baby tooth.The main preventive service recommended is the topical application of fluoride varnish every 3 to 6 months, 27 In the current study it is clear that 51% had no idea about the importance of visiting the dentist before there is a problem with the teeth of the child with the diversity of the academic level of mothers,Although 33% agreed and 17% disagreed.

CONCLUSION
Through the study above it is clear that the level of awareness and knowledge regarding nursing bottle caries is generally weak for mothers in the field of research with the diversity of their level of academic achievement and have no scientific background on how to take appropriate measures to protect their children from nursing bottle caries.In general, access to health awareness by citizens in general and mothers through health programs in public radio and television programs, And through the Ministry of Health, where there are no serious steps by the health program managers in the General Organization for Radio and Television and the sections of the Ministry of Health responsible for health awareness programs and health promotion and school health to raise awareness of citizens in general and mothers in particular about the causes of decay and how to take the necessary measures to prevent it As well as the importance of the presence of fluoride and the resulting use of prevention of decay, One of the main tasks of public health care is fostering responsibility of each person for his or her own health.In order to improve the quality and accessibility of public health care services to each citizen of the country the Ministry of Health drafts legal acts and programs, The main functions of public health care include co-ordination of implementation of municipal public health programs, monitoring trends in health condition changes of the municipal population, support and coordination of public health education and encouragement of the community involvement in solving public health problems. 28

Table ( 1
) Educational level status (ELS) of mothers