Children’s oral health is a vital component of general health and well-being, closely influenced by parental knowledge, attitudes and behaviours. Among the most prevalent dental diseases in early childhood is Early Childhood Caries (ECC), a preventable condition that poses a significant public health challenge worldwide, particularly in low- and middle-income countries [1]. In Saudi Arabia, ECC remains highly prevalent and continues to affect the quality of life and development of young children [2-4]. ECC is characterized by the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in children under six years of age. Despite being largely preventable through proper oral hygiene practices and timely dental visits, ECC persists at alarmingly high rates [5,6].   Parental education, socioeconomic status and cultural beliefs have been consistently identified as key determinants of children’s oral health. Studies from across the region and internationally support this association. In Kuwait, Alyahya found that higher levels of parental education correlated with improved oral hygiene behaviours in children [7]. In Saudi Arabia, Alshammari et al. reported moderate parental awareness in Dammam, with clear disparities based on socioeconomic status [8], while in Riyadh, Ansari et al. highlighted cultural misconceptions surrounding the perceived insignificance of primary teeth as a cause for delayed dental visits [9]. Globally, the American Academy of Paediatric Dentistry (AAPD, 2018) recommends the first dental visit to occur by the child’s first birthday [10]. However, adherence to this guideline remains low in Saudi Arabia, where dental visits are often reactionary rather than preventive. In Saudi Arabia it was reported by Sabbagh and Alzain that many parents in Riyadh only sought dental care when their child was already experiencing dental problems, resulting in more advanced and difficult-to-treat cases [11]. These findings align with international literature, which emphasized the critical role of early preventive measures in managing ECC [12,13]. Cultural beliefs and socioeconomic conditions significantly shape oral health behaviours and access to care. Studies show that misconceptions about the value of preventive care, such as flossing or regular check-ups, are prevalent in many provinces in Saudi Arabia [14-16]. ECC is defined as the presence of one or more decayed, missing or filled primary tooth surfaces in children under six years [5]. However, older children remain relevant when exploring parental practices, as oral hygiene behaviours established in early years extend into later childhood [6]. In Saudi Arabia, ECC prevalence remains high, with studies reporting rates between 62-80% among preschoolers [2-4]. Despite national initiatives, preventive care remains underutilized.   Parental influence is central to shaping oral health outcomes [7-9]. Mothers, in particular, play a pivotal role in establishing hygiene routines, dietary control and dental attendance. However, cultural misconceptions, such as the belief that primary teeth are unimportant or that dental care is necessary only when problems arise, remain barriers to prevention in Saudi Arabia [10-12].   While studies have been conducted in Riyadh, Dammam and Taif, limited evidence exists for Jeddah, a city characterized by socioeconomic and cultural diversity. This study therefore sought to evaluate parental knowledge, attitudes and practices (KAP) regarding children’s oral health in Jeddah, while identifying demographic factors influencing these domains.

Study Design and Setting A cross-sectional study was conducted between January and April 2024 in Jeddah districts (Al-Safa, Al-Faisaliyah and Al-Nahda). Participants were recruited from community health centres, public dental clinics, primary schools and through online distribution.   Participants   Inclusion criteria: Parents/guardians of children aged 0-12 years, residents of selected districts and those providing informed consent Exclusion criteria: Non-residents, individuals without children in the specified age group or those unwilling to consent   Sampling Stratified convenience sampling was used to ensure inclusion across districts and facilities. Although power analysis indicated a minimum of 250 participants (medium effect size, α = 0.05, power = 80%), the final sample included 257 respondents.   Data Collection Tool A structured, validated bilingual (Arabic/English) questionnaire was administered. It assessed: (1) sociodemographic details, (2) knowledge of oral health, (3) attitudes toward preventive care and (4) practices. Internal consistency was confirmed (Cronbach’s α = 0.82). Pilot testing was conducted on 20 parents and minor modifications were incorporated.   Statistical Analysis Data were analysed using SPSS v26.0. Descriptive statistics (frequency, percentage) summarized responses. Associations between KAP scores and sociodemographic variables were tested using Chi-square and Fisher’s Exact Tests. A p-value<0.05 was considered statistically significant.

Sociodemographic Characteristics Out of 257 participants, most were Saudi nationals (75.9%) and mothers (70.0%). The majority were between 26-45 years (61.5%) and resided in urban areas (98.1%). Over half had university education (61.1%), middle income (73.5%) and no chronic illness (71.2%) (Table 1).   Table 1: Sociodemographic characteristics of the participants Parameters Variable N % Nationality Saudi 195 75.9 Not Saudi 62 24.1 Parent Father 77 30.0 The mom 180 70.0 Age of the parent 15-25 year 53 20.6 26-35 year 81 31.5 36-45 year 77 30.0 46-55 year 27 10.5 > 55 years 19 7.4 Residence Urban‎/city 252 98.1 Rural‎/village 5 1.9 Educational level No primary education 5 1.9 Primary 12 4.7 Middle 18 7.0 Secondary 65 25.3 University 157 61.1 Employment Employed 128 49.8 Student 47 18.3 Other 82 31.9 Marital status Married 185 72.0 Divorced 22 8.6 Widow‎/widower 50 19.5 Income Low 33 12.8 Middle 189 73.5 High 35 13.6 Number children 1 83 32.3 2 60 23.3 3 57 22.2 4 57 22.2 Chronic disease Nothing 183 71.2 Diabetes Mellites 29 11.3 Hypertension 20 7.8 Other 25 9.7 Is this first child No 131 51.0 Yes 126 49.0   Knowledge Most parents knew caries is the most common dental disease (75.5%) and could identify causes (86.8%). However, only 26.5% knew about dental sealants and the correct timing for the first dental visit. Fluoride knowledge was moderate (57.6%). Overall knowledge levels: 44.1% good, 35.0% fair, 20.9% poor (Figure 1, Table 2-3).   Figure 1: Knowledge level of the participants   Table 2: Knowledge about Dental Health Question Response n (%) Do you know that tooth decay is the most common dental disease among children? Yes 194 (75.5%) No 63 (24.5%) Do you know the benefits of primary prevention for teeth? Yes 194 (75.5%) No 63 (24.5%) Are tooth decay and gum diseases hereditary or acquired? Acquired 214 (83.3%) Hereditary 43 (16.7%) Do you know the factors that cause tooth decay? Yes 223 (86.8%) No 34 (13.2%) Do you understand the importance of monitoring your child's diet, including the type and quantity of sugar intake? Yes 186 (72.4%) No 71 (27.6%) Do you know what dental sealants are and why they are important for children? Yes 68 (26.5%) No 189 (73.5%) Do you know how to properly clean teeth with a toothbrush? Yes 231 (89.9%) No 26 (10.1%) Do you know the correct timing and frequency recommended for brushing teeth? Yes 204 (79.4%) No 53 (20.6%) Do you know the importance of fluoride for children? Yes 148 (57.6%) No 109 (42.4%) When should children first visit a dentist? When teeth emerge 68 (26.5%) After one year 53 (20.6%) Do not know 136 (52.9%) Table 3: Knowledge Level by Demographic Variables Parameter Variable Knowledge Level P-value Poor n (%) Fair n (%) Good n (%) Nationality Saudi 36 (18.5%) 73 (37.4%) 86 (44.1%) <0.001 Non-Saudi 30 (48.4%) 17 (27.4%) 15 (24.2%) Parent Father 28 (36.4%) 22 (28.6%) 27 (35.1%) 0.035 Mother 38 (21.1%) 68 (37.8%) 74 (41.1%) Age (years) 15-25 11 (20.8%) 20 (37.7%) 22 (41.5%) 0.184 26-35 23 (28.4%) 24 (29.6%) 34 (42.0%) 36-45 18 (23.4%) 29 (37.7%) 30 (39.0%) 46-55 12 (44.4%) 10 (37.0%) 5 (18.5%) >55 2 (10.5%) 7 (36.8%) 10 (52.6%) Residence Urban/city 63 (25.0%) 88 (34.9%) 101 (40.1%) 0.112 Rural/village 3 (60.0%) 2 (40.0%) 0 (0.0%) Educational level No education 0 (0.0%) 4 (80.0%) 1 (20.0%) <0.001 Primary 11 (91.7%) 1 (8.3%) 0 (0.0%) Middle 12 (66.7%) 4 (22.2%) 2 (11.1%) Secondary 18 (27.7%) 28 (43.1%) 19 (29.2%) University 25 (15.9%) 53 (33.8%) 79 (50.3%) Employment Employed 39 (30.5%) 42 (32.8%) 47 (36.7%) 0.489 Student 10 (21.3%) 16 (34.0%) 21 (44.7%) Other 17 (20.7%) 32 (39.0%) 33 (40.2%) Marital status Married 52 (28.1%) 60 (32.4%) 73 (39.5%) 0.349 Divorced 3 (13.6%) 8 (36.4%) 11 (50.0%) Widowed 11 (22.0%) 22 (44.0%) 17 (34.0%) Income Low 17 (51.5%) 10 (30.3%) 6 (18.2%) 0.001 Middle 46 (24.3%) 68 (36.0%) 75 (39.7%) High 3 (8.6%) 12 (34.3%) 20 (57.1%) Number of children 1 24 (28.9%) 32 (38.6%) 27 (32.5%) 0.404 2 18 (30.0%) 21 (35.0%) 21 (35.0%) 3 12 (21.1%) 16 (28.1%) 29 (50.9%) 4 12 (21.1%) 21 (36.8%) 24 (42.1%) First child No 37 (28.2%) 48 (36.6%) 46 (35.1%) 0.354 Yes 29 (23.0%) 42 (33.3%) 55 (43.7%)   Attitudes   2% agreed that primary teeth are important 5% believed dental visits were only needed when problems occur 1% accepted sweets as unavoidable in children’s diets   Practices Although 93.4% reported regular brushing, only 47.1% of children brushed for 2-3 minutes and 17.1% used dental floss. Only 39.7% attended routine dental checkups every 3-6 months (Table 4-6).   Table 4: Practices related to Dental Hygiene and Care Question Response n (%) Have you visited a dentist before? Yes 251 (97.7%) No 6 (2.3%) Do you regularly take your child for a dental checkup every 3-6 months? Yes 102 (39.7%) No 155 (60.3%) Do you replace your child’s toothbrush every three months? Yes 152 (59.1%) No 105 (40.9%) Did you consult a dentist when your child's first tooth appeared? Yes 93 (36.2%) No 164 (63.8%) Did you take care to clean your child's gums before their teeth appeared? Yes 120 (46.7%) No 137 (53.3%) Do you regularly check your child's teeth at home? Yes 95 (37.0%) No 90 (35.0%) Not Sure 72 (28.0%)   Table 5: Child’s Oral Health Behaviours and Habits Question Response n (%) Does your child brush his/her teeth regularly? Yes 240 (93.4%) No 17 (6.6%) What type of toothbrush does your child use? Normal 230 (89.5%) Electric 27 (10.5%) Does your child know how to brush his/her teeth correctly? Yes 229 (89.1%) No 28 (10.9%) Have you taught your child the correct method of brushing teeth? Yes 225 (87.5%) No 32 (12.5%) Do you reward or praise your child during tooth brushing? Yes 138 (53.7%) No 119 (46.3%) Does your child brush his/her teeth for 2-3 minutes? Yes 121 (47.1%) No 136 (52.9%) Does your child use dental floss? Yes 44 (17.1%) No 213 (82.9%) Does your child brush his/her teeth more than once a day? Yes 165 (64.2%) No 92 (35.8%) Table 6: Dietary Habits and Oral Health Issues Question Response n (%) Does your child consume sugary food or drinks with meals or between meals? Between meals 171 (66.5%) During meals 86 (33.5%) Have you noticed any abnormalities or deformities in your child's mouth? Yes 56 (21.8%) No 201 (78.2%) Has your child complained about pain or discomfort in the mouth or gums? Yes 149 (58.0%) No 108 (42.0%) Does your child have other oral habits (e.g., thumb sucking, nail-biting)? Yes 93 (36.2%) No 164 (63.8%) Does your child receive an adequate amount of fluoride? Yes 171 (66.5%) No 86 (33.5%) What is the source of fluoride your child receives? Toothpaste 151 (58.8%) Water 55 (21.4%) Topical application 17 (6.6%) Other 34 (13.2%)

The findings of this study reveal encouraging levels of general awareness among parents in Jeddah regarding children's oral health, particularly in relation to the causes and prevention of tooth decay. A significant proportion of respondents (75.5%) identified dental caries as the most common childhood oral disease and demonstrated a solid understanding of primary preventive measures. This aligns with findings from a study in India by Mishra et al., which also reported high parental recognition of caries and its preventability [19]. Furthermore, a majority of participants (83.3%) correctly believed that dental caries and gum diseases are acquired conditions rather than hereditary, which is consistent with the health education principles promoted by the American Academy of Paediatric Dentistry [20]. Similarly, the high proportion (86.8%) who understood the contributing factors of tooth decay supports the findings of a systematic review and recent meta-analysis by Khan et al. [21] done in Saudi Arabia, who stressed that parental knowledge of sugar consumption and oral hygiene practices significantly correlated with lower caries prevalence.   Knowledge about practical oral hygiene techniques was also strong, with 89.9% of participants indicating they knew how to brush properly and 79.4% correctly identifying the recommended frequency and timing of brushing. These results are comparable to those reported by AlShammari et al. in Dammam, where parents showed moderate to high awareness of oral hygiene routines [8]. However, the findings also revealed critical knowledge gaps. About 26.5% of parents were aware of the role and importance of dental sealants, which is a preventive intervention shown to be effective in reducing caries incidence, especially in molars as demonstrated by multiple studies [22-24]. This mirrors findings from Al-Agili et al. in Saudi Arabia, where parental knowledge of dental sealants was found to be very low, suggesting an ongoing need for targeted public education on preventive dental treatments. Furthermore, while 57.6% recognized the benefits of fluoride for children, this remains lower than ideal. In contrast, a study by Timms and colleagues exploring the experiences of parents in the UK and USA found that while the majority of parents in Sheffield (73%) and Colorado (72%) were willing to accept fluoride treatment for their children’s posterior teeth, acceptance dropped to 58% for anterior teeth in both groups. Parental concerns about dental aesthetics significantly influenced acceptability, particularly for anterior teeth and also affected acceptance of posterior teeth in the UK sample, highlighting the aesthetic barrier to broader use of fluoride [26]. Perhaps the most concerning finding was that over half of the participants (52.9%) were unaware of the recommended timing for the child’s first dental visit, with only 26.5% correctly identifying it as when the first tooth erupts. This gap is consistent with previous studies in Eastern Province and Riyadh province of Saudi Arabia, which also highlighted poor parental knowledge regarding early dental visits [18,27]. International guidelines, such as those by the AAPD, recommend the first dental visit by age one [10] and studies in countries like Latvia and Lithuania have shown higher parental compliance with these recommendations, particularly when early dental education is emphasized [28,29].   In our study Saudi parents had significantly better knowledge about children's oral health compared to non-Saudis (44.1% vs. 24.2%, p<0.001), a pattern that aligns with previous studies in Saudi Arabia suggesting that familiarity with local health education initiatives may contribute to increased awareness among nationals [8,30]. Mothers were also more knowledgeable than fathers (41.1% vs. 35.1%), which is consistent with global and regional literature emphasizing the central role of mothers in child health behaviours [30,31]. Educational attainment had a strong association with knowledge levels, with university-educated participants demonstrating the highest proportion of good knowledge, echoing findings by Mishra et al. and Al-Malik et al., who highlighted the positive impact of higher education on oral health awareness [19,16]. Likewise, income level significantly affected knowledge, as higher-income families exhibited better knowledge compared to lower-income groups, a trend reported in both local and international studies [13,29,32]. Interestingly, no significant associations were found between knowledge and age, residence, employment, marital status, number of children or first-child status, suggesting that socioeconomic and educational variables may be more critical predictors than basic demographic characteristics, which is in contrastto some earlier assumptions that parenting experience alone improves oral health literacy.   The current study findings showed that while the vast majority of participants (97.7%) had taken their child to the dentist at least once, adherence to recommended preventive dental care practices was suboptimal. Fewer than half of the parents (39.7%) scheduled regular dental checkups every 3-6 months and only 36.2% sought dental consultation upon the eruption of their child’s first tooth, reflecting poor compliance with early dental care guidelines recommended by the AAPD [10]. Additionally, less than half (46.7%) reported cleaning their child’s gums before tooth eruption and only 37.0% regularly inspected their child’s teeth at home, both of which are essential preventive measures for early detection and oral hygiene establishment. Nevertheless, a relatively higher proportion (59.1%) reported replacing their child’s toothbrush every three months, which is consistent with recommended hygiene practices. These findings indicate a gap between awareness and consistent preventive behaviour, a pattern also demonstrated in studies from other Middle Eastern settings [27,33] emphasizing the need for reinforcing practical parental engagement through structured oral health education initiatives.   The study revealed generally positive oral hygiene habits among children, with most brushing regularly and demonstrating proper technique, likely influenced by the high rate of parental instruction reported. These findings align with Pullishery et al., who noted that active parental involvement significantly shapes children’s oral hygiene behaviour [34]. However, less than half met the recommended brushing duration of 2-3 minutes, reflecting a common gap between routine and best practices, as similarly observed in AAPD guidelines [10]. The minimal use of dental floss parallels results from AlShalan et al., emphasizing the continued neglect of interdental cleaning in local populations [27. High consumption of sugary foods between meals remains a concern, reinforcing the established link between dietary habits and early childhood caries [35]. Compared to lower sugar intake levels reported in Canadian and European cohorts with strong parental regulation [28,32], these findings point to the need for dietary education. The presence of oral abnormalities and parafunctional habits such as thumb sucking suggests a behavioural component requiring attention through early intervention. While fluoride exposure was adequate in most children, it was primarily limited to toothpaste use, with limited contribution from water or professional applications. This differs from countries with systemic water fluoridation, where broader exposure enhances caries prevention [36].   This study highlights satisfactory parental awareness in Jeddah regarding general oral health but reveals significant deficiencies in preventive knowledge and practices. The low awareness of sealants (26.5%) and poor compliance with first dental visit guidelines (26.5%) are concerning. These findings align with earlier Saudi studies [8,11,25], emphasizing the gap between awareness and preventive behaviour.   The omission of preventive practices is critical, as fluoride and sealants significantly reduce caries incidence [22-25]. The attitudinal finding that nearly half of parents delayed dental visits until problems arose reflects a reactive care model, inconsistent with AAPD recommendations [10].   Sociodemographic analysis showed mothers, higher-educated and higher-income parents demonstrated superior knowledge, consistent with prior Saudi and international studies [19,30-32]. However, reliance on Chi-square testing without multivariate models limits conclusions about independent predictors.   Clinically, the high sugar consumption (66.5%) and low flossing rates (17.1%) indicate an urgent need for behaviour-focused education. School-based interventions and parent-focused campaigns are warranted.

Parental knowledge of general oral health in Jeddah is encouraging, yet preventive gaps, especially regarding sealants, early visits, flossing and brushing duration, remain pronounced. Mothers and higher socioeconomic groups exhibit better awareness, but misconceptions persist. Tailored education programs addressing cultural and behavioural barriers are essential to reduce ECC prevalence. Future studies should integrate longitudinal and interventional designs with clinical assessments.   Ethical Statement Approval was obtained from the Ethics Committee of Batterjee Medical College (Approval No: BMC-REC-2024-011). Written/electronic informed consent was obtained from all participants. Confidentiality and anonymity were assured.