Forty-nine interviews with 26 Mexican immigrant caregivers, all mothers, were conducted within a 9 month period between 2005 and 2006. This was a predominantly low-income and recently-arrived immigrant population: Caregivers had been in the U.S. a mean of eight and a half years and had a mean annual household income of $17,000; all were at or below poverty level. Eighty percent came from rural towns of a population of 15,000 or less (See ).
SOCIODEMOGRAPHIC CHARACTERISTICS OF CAREGIVERS BORN IN MEXICO
Analysis of the interviews allowed us to derive a model of how rural low-income Mexican immigrant caregivers interpreted children’s dental symptoms and evaluated the need for treatment (See ). Caregivers’ decisions to seek help were based on a combination of their recognition of a visible problem and their acceptance of their children’s complaints of pain. While caregivers of infants could only rely upon visible changes to their children’s teeth as an indication of disease, caregivers of small children relied upon both visible changes and children’s complaints of pain.
Mexican Immigrant Caregivers’ Interpretations of Children’s Dental Symptoms
Conceptions of “Healthy Teeth”
Mexican immigrant caregivers generally defined “healthy” teeth as those that were “white,” and “clean,” and pain-free (c.f. Watson et al., 1999
). Caregivers viewed the absence of symptoms – both of a visible problem and of the child’s complaint of pain – as an absence of disease. For example, one immigrant mother said that she had not taken her two-year old son for a checkup because “he is still small and I can see that his teeth are good and white.” A second mother said that she saw no need to take her five-year-old daughter in for a first dental visit. “Her teeth are white and clean,” she explained. Thus most immigrant caregivers deduced the health of their children’s teeth from their appearance and did not see the need for asymptomatic visits.
Recognizing a Visible Problem
Caregivers’ interpretations of infants’ oral health relied mainly on visible changes to infants’ teeth. Yet the question, “Does your child have any cavities or dental problems?” unexpectedly elicited caregivers’ alternative interpretations of their children’s oral disease. Nine of 26 caregivers in our sample specifically interpreted their children’s tooth decay as “stains,” or “manchas,” rather than as “cavities.” One mother, for example, explained that she decided to take her 1½ year old son to the dentist when she saw what she described as “little black points” on his front teeth-- “stains that were black.” “That’s why we decided to take him to the dentist, that’s when the dentist said that they were cavities,” she said. Because of his young age and her lack of experience with seeing infants with tooth decay, this immigrant mother was not aware that such “black points” constituted decay. Another mother similarly maintained that she had not seen any “cavities” before her son visited the dentist and received several fillings; she had seen only “two little brown stains” on his molars.
Caregivers generally viewed children’s “stains” as simple discolorations that could be removed through brushing or “cleanings” (“limpianzas”) rather than as bacterial infections that required restorative treatment. For example, one mother believed that the act of brushing her three-year-old child’s teeth could remove the brown stains she saw. “I saw that his teeth were ugly, so I told him that he had to brush so that his teeth would grow out nice,” she said. Five caregivers specifically said that what prompted their decision to take their children to the dentist was their desire to get their children a “cleaning” to remove “stains.” One mother, for example, said of her seven-year-old: “Her teeth became stained and I had to take her to the doctor [dentist] so he could clean them.” “Cleanings” were viewed as not only aesthetic but as preventive of the pain that is caused by tooth “rotting.”
This different view of the treatment “stains” required became particularly evident during observations of immigrant caregivers’ presentation of their children’s dental symptoms in dental clinics. For instance, one Mexican immigrant father brought his three-year-old daughter to a dental clinic specifically requesting that she receive a “cleaning.” Staff responded that the child would need a general examination as these “stains,” adjacent to the gum line on her upper front teeth, bore the hallmarks of ECC. The father did not understand why his daughter needed more extensive treatment than a simple cleaning, nor did he think such “stains” required urgent treatment. Because immigrant caregivers were unaware that their children’s decay constituted a form of oral disease, many delayed help-seeking.
A Visible Problem, Confirmed by Audible Complaints
In evaluating the need to take children to the dentist, caregivers relied upon two main forms of data: 1) visible signs of a “problem” and 2) children’s complaints of pain. Children’s complaints of pain alone were less effective than visible signs of a “problem” in triggering a dental visit. While parents viewed children’s complaints of pain as an important indicator of the need for treatment, they did not always believe children’s complaints without corroborating visible evidence.
Like immigrant parents of various cultural origins (Harrison and Wong, 2003
; Hilton et al., 2007
; Wong et al., 2005
), many of the immigrant caregivers we interviewed did say that permanent teeth were more important than primary teeth. Yet while immigrant caregivers viewed primary teeth as of less consequence, they viewed children’s pain as of greater concern than adults’ pain. When asked for whom they would first seek care if an adult and a child in their family both suffered dental pain yet resources were scarce, 24 of 26 caregivers responded that they would seek care for the child first. Reflecting this common sentiment, one mother said of her son, “I would fix his because he comes first.” Thus caregivers placed their children’s health needs above their own, and were likely to take a child for a dental visit if they believed that their children were indeed experiencing pain.
Their children, however, did not always complain of pain unless asked. One mother, for example, said that it was not until she saw her child’s swollen gum that she asked whether a previously-filled molar was hurting her seven-year-old. When he said “yes,” she took him to the dentist, who had to extract the molar. While this caregiver’s concern was triggered by the visible symptom of her son’s swollen gum, the child’s report of pain confirmed the need for an immediate dental visit.
No Visible Problem, But Audible Complaints
Caregivers interpreted their children’s visible symptoms, confirmed by a report of pain, as constituting an oral health “problem” requiring a dental visit. Yet in the absence of visible symptoms, caregivers did not always believe their children’s complaints of pain. Eight caregivers were not aware that their children were suffering from decay until it had progressed to the point of severe problems such as abscesses, swollen faces, and stomach infections.
A mother, for example, said of her 5-year-old son’s daily complaints of molar pain:
I thought that he was just making it up because I would check his teeth and I would not be able to see the cavities... I would tell him, ‘How can your molar be hurting?’ Until one day he had this big bump-- it’s a blister (postemilla) filled with pus and that side of his face was swollen, and I took him in to the dentist and that’s when they told me that he had a bad infection.
Similarly, another mother was unaware of her 8-year-old son’s severe pain until he was sent home from school complaining of an “ear ache.”
My son, one day the school called me, they called me because he had an ear ache and his side of his face was swollen. I took him to the doctor and the doctor said that it was not the ear, it was the cavity that was affecting him.
Again, another mother said she did not believe her 3-year-old daughter when the child began complaining of pain in her back teeth because she saw no evidence of a problem:
She would always complain that her molars would hurt but I would not believe her because I would say, ‘what does she know of molar pain? she is so small,’ plus I have never had any tooth aches and I did not listen to her.
As this quote indicates, it is important to place caregivers’ skepticism of children’s complaints of pain in the context of caregivers’ own experiences with oral disease as children. All but two of the 26 caregivers reported having experienced neither dental pain nor having visible dental symptoms as young children in rural parts of Mexico. A mother, who received her first toothbrush at age 12, said:
When I was small I did not even know what a tooth brush was because we lived in a small ranch and like we were nine children--we were really poor--but I don’t ever remember having a toothache.
Because of their lack of experience with ECC, then, many caregivers stated that they were taken by surprise by their children’s oral disease. In commenting on the difference between the environment in which her eldest four Mexico-born children had been raised and that in which she had raised her youngest US-born daughter, a mother said “It’s only my youngest that has had dental problems; my eldest have not had them. I think it’s because of the water and because what they eat is so different here.” Because of their own different experiences with oral disease in rural Mexico, then, many caregivers were quick to dismiss their children’s complaints of pain in the absence of visible symptoms.