THE VALIDITY GAP AND PREMATURE
AUTONOMY: REFRAMING PEDIATRIC ORAL
HEALTH IN LATIN AMERICA
LA BRECHA DE VALIDEZ Y LA AUTONOMÍA PREMATURA:
REPLANTEANDO LA SALUD BUCAL PEDIÁTRICA EN
AMÉRICA LATINA
Juana Aurelia Sarmiento Porras
Universidad Autónoma Benito Juárez de Oaxaca – México
Homero Caballero Sánchez
Universidad Autónoma Benito Juárez de Oaxaca – México
Alicia Hernández Antonio
Universidad Autónoma Benito Juárez de Oaxaca – México
César Zárate-Ortiz
Universidad Autónoma "Benito Juárez" de Oaxaca– México
Luis Alberto Martínez Hernández
Universidad Autónoma Benito Juárez de Oaxaca - México
Mercedes Rosas Hernández
Universidad Autónoma Benito Juárez de Oaxaca - México
Patricia Ramírez Cortez
Universidad Autónoma Benito Juárez de Oaxaca - México
Taurino Amilcar Sosa-Velasco
Universidad Autónoma Benito Juárez de Oaxaca - México

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DOI: https://doi.org/10.37811/cl_rcm.v10i1.22147
The Validity Gap and Premature Autonomy: Reframing Pediatric
Oral Health in Latin America
Juana Aurelia Sarmiento Porras1
juanaaureliasarmientoporras@gmail.com
https://orcid.org/0009-0001-5166-5390
Facultad de Medicina y Cirugía
Universidad Autónoma Benito Juárez de Oaxaca
Oaxaca México
Homero Caballero Sánchez
homerosalud@gmail.com
https://orcid.org/0000-0002-8529-0224
Facultad de Odontología
Universidad Autónoma Benito Juárez de
Oaxaca
Oaxaca México
Alicia Hernández Antonio
cd.alisha@gmail.com
https://orcid.org/0000-0001-5198-6023
Facultad de Odontología
Universidad Autónoma Benito Juárez de Oaxaca
Oaxaca, México
César Zárate Ortiz
cesareoivo02@gmail.com
https://orcid.org/0009-0004-0957-469X
Laboratorio de Bioquímica de Proteínas y
Glicopatologías, Facultad de Odontología
Universidad Autónoma "Benito Juárez" de
Oaxaca
Oaxaca, México
Luis Alberto Martínez Hernández
Luisinhood1@gmail.com
https://orcid.org/0009-0000-0234-928X
Facultad de Enfermería y Obstetricia
Universidad Autónoma Benito Juárez de Oaxaca
Oaxaca, México
Mercedes Rosas Hernández
mercedesrosas0798@gmail.com
https://orcid.org/0009-0005-7441-0883
Facultad de Enfermería y Obstetricia
Universidad Autónoma Benito Juárez de
Oaxaca
Oaxaca, México
Patricia Ramírez Cortez
pattyrc@yahoo.com
https://orcid.org/0009-0004-2413-3999
Facultad de Enfermería y Obstetricia
Universidad Autónoma Benito Juárez de Oaxaca
Oaxaca, México
Taurino Amilcar Sosa Velasco
asosa.faeo@uabjo.mx
https://orcid.org/0000-0002-0852-9748
Facultad de Odontología
Universidad Autónoma Benito Juárez de
Oaxaca
Oaxaca, México
1 Autor principal
Correspondencia: asosa.faeo@uabjo.mx

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ABSTRACT
Background: Early Childhood Caries (ECC) remains a persistent public health problem in Latin
America, affecting a majority of preschool children despite high levels of parental awareness regarding
oral hygiene. This paradox highlights limitations of traditional prevention strategies that rely primarily
on information delivery. Problem Analysis: This perspective synthesizes evidence from pediatric
dentistry, behavioral science, and preventive medicine to identify two underrecognized barriers to
effective ECC prevention. First, the “Validity Gap” refers to the discrepancy between caregiver-
reported oral hygiene practices and objectively observed behaviors, largely driven by social desirability
bias and misinterpretation of technical competence. Second, “Premature Autonomy” describes the
widespread developmental misconception that young children possess the fine motor skills required for
effective biofilm disruption, leading to early withdrawal of parental assistance. Conceptual
Proposal: Reframing pediatric oral health as a core component of puericulture, we argue for a shift from
passive advice toward active coaching and objective verification within primary pediatric care. Drawing
on existing evidence, we outline a conceptual framework that emphasizes visual assessment tools (e.g.,
plaque disclosing agents), early clinical surveillance (“lift-the-lip” examinations), assisted brushing
aligned with neurodevelopmental readiness (the “7-Year Rule”), and simulation-based caregiver
education. Conclusion: Addressing ECC requires moving beyond knowledge transmission to focus on
behavioral execution and developmental capacity. Integrating oral health into routine pediatric
surveillance and adopting coaching-based preventive strategies may help bridge the translational gap
between parental intent and effective home practice, positioning the oral cavity as a meaningful indicator
of systemic child health.
Keywords: puericulture, early childhood caries, pediatric oral health, health literacy, preventive
medicine

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La brecha de validez y la autonomía prematura: replanteando la salud bucal
pediátrica en América Latina
RESUMEN
Antecedentes: La caries de la primera infancia (CPI) continúa siendo un problema persistente de salud
pública en América Latina, afectando a la mayoría de los niños en edad preescolar a pesar de los altos
niveles de conocimiento parental sobre higiene bucal. Esta paradoja pone en evidencia las limitaciones
de las estrategias preventivas tradicionales que se basan principalmente en la transmisión de
información. Análisis del problema: Esta perspectiva sintetiza evidencia proveniente de la odontología
pediátrica, las ciencias del comportamiento y la medicina preventiva para identificar dos barreras poco
reconocidas en la prevención efectiva de la CPI. En primer lugar, la “brecha de validez” se refiere a la
discrepancia entre las prácticas de higiene bucal reportadas por los cuidadores y los comportamientos
observados de manera objetiva, impulsada en gran medida por el sesgo de deseabilidad social y la
interpretación errónea de la competencia técnica. En segundo lugar, la “autonomía prematura” describe
la concepción errónea, ampliamente difundida, de que los niños pequeños poseen las habilidades
motoras finas necesarias para una adecuada disrupción del biofilm, lo que conduce a la retirada temprana
de la asistencia parental. Propuesta conceptual: Al replantear la salud bucal pediátrica como un
componente central de la puericultura, se propone un cambio desde el consejo pasivo hacia el
acompañamiento activo y la verificación objetiva dentro de la atención pediátrica primaria. A partir de
la evidencia existente, se plantea un marco conceptual que enfatiza el uso de herramientas de evaluación
visual (por ejemplo, agentes reveladores de placa), la vigilancia clínica temprana (exámenes de “levantar
el labio”), el cepillado asistido alineado con la madurez del neurodesarrollo (la “regla de los 7 años”) y
la educación de cuidadores basada en simulación. Conclusión: Abordar la CPI requiere ir más allá de la
transmisión de conocimientos para centrarse en la ejecución conductual y la capacidad del desarrollo.
La integración de la salud bucal en la vigilancia pediátrica rutinaria y la adopción de estrategias
preventivas basadas en el acompañamiento activo pueden ayudar a cerrar la brecha traslacional entre la
intención parental y la práctica efectiva en el hogar, posicionando la cavidad oral como un indicador
significativo de la salud sistémica infantil.
Palabras clave: puericultura, caries de la primera infancia, salud bucal pediátrica, alfabetización en
salud, medicina preventiva
Artículo recibido 10 diciembre 2025
Aceptado para publicación: 10 enero 2026

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INTRODUCTION
The Mouth as the Mirror of the Child
The oral cavity functions as a sensitive biological barometer for the pediatric patient, serving as much
more than a portal for alimentation; it is a sentinel for systemic well-being (1). Far from being an isolated
anatomical entity, the mouth often provides the earliest clinical evidence of underlying pathologies,
where mucosal alterations, gingival inflammation, and periodontal changes act as visible indicators of
internal physiological states (2, 3). The oral environment offers a unique diagnostic window by
signaling nutritional deficiencies, hematological disorders, and autoimmune conditions such as
Systemic Lupus Erythematosus, in which microvascular damage and inflammatory responses are
pervasive (4-6). By observing these manifestations, clinicians can access a reflection of the child's
overall inflammatory burden and immune competence, potentially facilitating earlier intervention in
complex systemic diseases.
This integrated biological perspective aligns seamlessly with the foundational goals of pediatric care.
Puericulture, in its truest definition, is the scientific cultivation of the child (7). It is the branch of
preventive medicine that transcends the mere treatment of acute illness, focusing instead on the optimal
physiological and psychological development of the pediatric patient. By definition, this discipline
requires a comprehensive stewardship of health, presupposing that the monitoring of growth and
development must encompass every physiological system without exclusion (8). However, a profound
paradox persists between this established biological interconnectivity and the prevailing operational
structure of pediatric healthcare (9). Although the child's physiology functions as a unified whole,
medical management is frequently bifurcated at the oral cavity, effectively treating the mouth as an
entity separate from the systemic circulation it directly influences (10). This clinical fragmentation
overlooks the critical role of oral biomarkers and local inflammation in the progression of systemic
disease, necessitating a critical examination of the historical and structural factors that have entrenched
this divided approach.

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DEVELOPMENT
The Current Landscape: Puericulture and the Oral-Systemic Divorce
Puericulture is the branch of preventive medicine that transcends the mere treatment of acute illness,
focusing instead on the optimal physiological and psychological development of the pediatric patient
(11). As clinicians and public health specialists, we have long accepted that the child is an integrated
biological system, yet in practice, we frequently observe a surgical separation of the mouth from the
body (12). For decades, the oral cavity has been relegated to the periphery of pediatric care, viewed as
a separate domain managed exclusively by dentists, rather than an integral component of general health.
This segregation is medically and epidemiologically untenable, particularly in the context of Mexico
and Latin America (13). Overcoming such fragmentation is a critical step toward bridging the
translational gaps that currently impede the transformation of the region's biomedical landscape (14).
The mouth is not merely a mechanical gateway for nutrition; it is an immunological interface and a
mirror of systemic health (15). Oral diseases, specifically Early Childhood Caries (ECC) and gingivitis,
do not exist in a vacuum (16). They share critical, modifiable risk factors with the very non-
communicable diseases (NCDs) that currently overwhelm our public health systems: obesity, type 2
diabetes mellitus, and cardiovascular disease (17). The common denominator is the cariogenic
environment, a state characterized by the frequent consumption of free sugars and poor hygiene that
drives both metabolic dysregulation and oral biofilm dysbiosis (18). Current evaluations of body mass
index in Mexican adolescents further emphasize the critical need for precise surveillance tools to identify
these compounding chronic health risks early (19). In a region where childhood obesity rates are among
the highest in the world, the pediatrician who ignores the mouth ignores a fundamental warning sign of
the child’s overall metabolic trajectory (20). Therefore, effective puericulture must reclaim the oral
cavity as a fundamental component of pediatric care. It is imperative to recognize that the "First 1000
Days ", the critical developmental window from conception to the second birthday, is just as essential
for the establishment of the oral microbiome as it is for neurological and immunological maturation. If
we fail to integrate oral hygiene coaching into the standard well-child visit, we are failing in our primary
duty of prevention.

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Epidemiology: The Silent Epidemic of Awareness without Action
Despite the global advancement of medical science, ECC remains a pervasive and stubborn public health
challenge. It is a global health problem affecting nearly 50% of the population, with prevalence varying
widely across continents (21). In developing nations and specific regions of Latin America, these
numbers can be significantly higher, exacerbated by socioeconomic disparities and dietary transitions
toward processed, sugar-dense foods (22).
The paradox of this epidemic lies in the high level of parental "awareness" (23). Public health campaigns
have succeeded in teaching parents that brushing is important (24). However, this superficial awareness
has not translated into disease reduction. Prevalence rates remain high, and dental caries continues to be
the single most common chronic disease of childhood, five times more common than asthma (25). This
suggests that the prevailing strategy of information dissemination, characterized by passive education
through pamphlets and brief verbal reminders, has reached a saturation point of diminishing returns.
Consequently, we are facing a crisis defined not by a lack of knowledge, but by a failure of execution.
The Behavioral Disconnect: Knowledge Does Not Equal Behavior
The central thesis of this manuscript is that the persistence of oral disease is driven by a profound
"Knowledge-Behavior Gap". We must dismantle the assumption that a parent who knows brushing is
important possesses the skill or efficacy to perform it correctly. Recent evidence from the Global South
provides a stark illustration of this disconnect. A cross-sectional survey conducted in India, a context
sharing many socioeconomic parallels with Mexico, revealed that 100% of primary caregivers agreed
that maintaining good oral hygiene in their children was important (26). Yet, this universal agreement
collapsed when examining actual practice. The same study revealed that a staggering 73% of these
parents had never received any information or education pertaining to the maintenance of oral hygiene
(26). They knew why to brush, but nobody had ever taught them how.
This lack of technical training leads to dangerous adaptations. It was reported that 59% of preschool
children were brushing their teeth independently, engaging in this activity without adult supervision
(27). In the context of puericulture, this is equivalent to allowing a preschooler to administer their own
insulin or antibiotics. A child under the age of six lacks the manual dexterity (visual-motor integration)
required to disrupt the biofilm effectively (28). This "premature autonomy" is a direct failure of the

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medical home to provide anticipatory guidance, leaving the child vulnerable to disease despite the
parents' good intentions.
Furthermore, we must address the "Validity Gap" in our clinical history-taking. As clinicians, we rely
heavily on parental reporting, but evidence suggests this data is often flawed. Video observation
protocols were employed in Malaysia to critically assess the concordance between parent-reported
behaviors and actual practices (29). The discrepancies were profound. While 35% of parents reported
using the recommended pea-sized amount of toothpaste, video evidence revealed that only 28% actually
did so (27). Conversely, parents over-reported the use of fluoridated toothpaste compared to what was
observed.
This phenomenon is attributed to social desirability bias, the tendency of parents to report what they
believe the doctor wants to hear (30). In the specific case of Khan’s study, parents claimed high
adherence to hygiene standards, yet 100% of the children presented with "poor" pre-brushing plaque
scores (27). This confirms a critical reality for the Mexican pediatrician: the anamnesis is insufficient.
When a parent says, "Yes, we brush twice a day," they may honestly believe they are performing the
task correctly, while in reality, the technique, duration, or supervision is entirely inadequate. The study
by Khan et al. demonstrated that specific behaviors such as toothbrushing technique, duration, and
parental guidance explained 86% of the variance in plaque score changes (27). This finding confirms
that the efficacy of the practice relies far more on the quality of execution than on the simple presence
of the habit. Recognizing that mechanical competence rather than lack of knowledge is the primary
barrier to oral health, it becomes evident that the traditional model of verbal instruction is insufficient
to ensure effective home care. To bridge this translational gap, pediatric practice must undergo a
fundamental paradigm shift.
Thesis Statement: From Passive Advice to Active Coaching
If knowledge is not the bottleneck, then more information is not the solution (31). To alter the trajectory
of oral health in Latin America, we must shift our paradigm from "passive advice" to "active coaching."
This manuscript argues that modern puericulture must adopt the methods of behavioral science and
simulation education. We cannot simply tell parents to "brush better"; we must simulate the behavior,
correct the technique in real-time, and utilize modern tools to reinforce habits. As demonstrated by Chen

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J. et al. (2025), interventions that move beyond conventional lectures to include "simulation education"
(role-playing, gamification) yield significantly better outcomes, reducing adverse oral behaviors and
increasing the use of fluoride toothpaste to over 90% (32).
In the following sections, we will outline a practical, evidence-based protocol for the primary care
physician. We will dissect the mechanics of effective hygiene, challenge the myths of the "independent
brusher," and propose a new model of "digital puericulture" suitable for the smartphone era. The goal is
to empower the pediatrician to act not just as a prescriber of medicine, but as a coach of preventive habit,
ensuring that the mouth remains a healthy mirror of the child's future well-being.
This article is a perspective grounded in the synthesis of existing empirical and conceptual evidence
rather than a formal clinical guideline, with the aim of reframing pediatric oral health within the
preventive framework of puericulture.
The Validity Gap: Why We Cannot Trust the Anamnesis Alone
In the routine practice of pediatric preventive medicine, the anamnesis serves as the cornerstone of
diagnosis, representing the clinical history derived directly from interviewing the parent or caregiver
(33). We rely on the parent’s narrative to gauge nutrition, sleep patterns, and developmental milestones.
However, when it comes to oral hygiene, this reliance on subjective reporting introduces a critical
"Validity Gap." The anamnesis is inherently filtered through the parent's perception, memory, and,
crucially, their desire to be viewed as a "good parent" by the clinician (34). This phenomenon, often
termed social desirability bias, renders standard questions like "Do you brush your child's teeth?" or "Do
you use fluoride?" diagnostically fragile. The fundamental difficulty arises because toothbrushing
functions as a complex motor skill rather than a binary event. Although a parent may honestly report
brushing twice daily, the actual efficacy regarding the physical removal of biofilm often remains
negligible (35). Without objective verification, the pediatrician is navigating blindly, assuming
protection where none exists. This disconnect between reported effort and clinical reality is a primary
reason why disease rates remain high despite high reported compliance.
To understand the magnitude of the gap between clinical history and home reality, the study by Khan et
al. serves as a pivotal reference point for challenging the reliability of parental reporting (27). Through
a rigorous cross-sectional analysis of 92 preschool children, the researchers utilized video-based

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behavioral observation to contrast parental questionnaire responses with objective practice. The results
revealed alarming statistical discrepancies across all metrics. Regarding toothpaste quantity, video
evidence confirmed that only 28% of participants actually used the recommended pea-sized amount
despite 35% of parents reporting compliance. A similar disconnect was evident in product selection,
where 74% of parents claimed to use appropriate fluoridated toothpaste, yet only 50% were observed
doing so. Perhaps most significantly, while over half of the parents claimed to guide their children
occasionally, actual video analysis demonstrated that only 11% provided verbal or practical
involvement, with the vast majority standing by passively while the child brushed ineffectively.
Interestingly, the validity gap does not always lean toward over-reporting positive behaviors;
sometimes, observation alters behavior in the opposite direction. Khan et al. noted that while 40% of
parents reported a brushing duration of 30 seconds to 1 minute, the video observation showed that 51%
of children actually brushed for 1 to 2 minutes. At first glance, this seems like a positive finding—
children brushing longer than expected (Table 1). However, the authors speculate this was likely a
manifestation of the "Hawthorne Effect," where subjects modify their behavior in response to being
observed (36). The children had been applied with a plaque-disclosing dye prior to brushing, and their
extended duration was likely an attempt to visually remove the stain they could see in the mirror. This
underscores that even "observed" behavior in a clinical setting may be an idealized performance rather
than a reflection of the daily routine at home. This discrepancy between performative compliance and
domestic reality necessitates a critical reexamination of preventive strategies within the Mexican
healthcare system.
For the Mexican pediatrician and public health specialist, these findings are a call to update our
diagnostic protocols (37). We operate within a cultural context comparable to the populations studied in
which deference to medical authority frequently compels parents to provide the expected answer rather
than a truthful account of actual practices (38). Simply asking "Do you brush?" acts as a binary
checkpoint that fails to capture the nuance of the habit. It provides a false sense of security. When a
parent reports compliance with toothbrushing, we must operate under the evidentiary assumption that
they are likely overestimating their level of supervision, misjudging the quantity of fluoride applied, and
underestimating the manual dexterity necessary for effective plaque removal (39). The "Validity Gap"

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means that a verbal confirmation of hygiene is not a confirmation of health. Consequently, to ensure
diagnostic accuracy, the clinical encounter must evolve from a passive interview into an active, objective
verification of skill. To effectively bridge the translational gap between parental reporting and clinical
reality, pediatric practice must transition from subjective interrogation to objective auditing. The most
potent instrument for this paradigm shift is the utilization of Plaque Disclosing Agents (40). The
application of these agents serves a dual function, primarily establishing diagnostic truth by instantly
exposing the validity gap; a child who purportedly brushes daily yet exhibits significant biofilm staining
provides irrefutable evidence of ineffective technique. Khan et al. validated this approach by recording
pre- and post-brushing plaque scores to quantify the precise variance between effort and outcome (27).
Secondarily, this mechanism induces a necessary educational shock that shatters the illusion of
competence. As observed in the Khan study, the immediate visual feedback provided by the dye
significantly motivated subjects to extend brushing duration in an attempt to remove the stain. This
process transforms the consultation from a passive lecture into an active, visual audit of mechanical
efficacy (27). Ultimately, while the anamnesis remains a necessary starting point, the evidence confirms
it is an insufficient diagnostic endpoint. The Validity Gap demonstrates that parental intent does not
equal mechanical competence, rendering the traditional verbal interview diagnostically fragile. To truly
protect the pediatric patient, the clinician must transcend the role of a passive interviewer and adopt the
tools of an active auditor. By implementing visual verification through plaque disclosing agents, we
replace subjective narrative with objective reality, ensuring that the "Mirror of the Child" reflects not
merely a hopeful history, but a validated picture of physiological health. However, the visual audit
identifies the presence of the deficit, but not the cause. To understand why widely accepted hygiene
routines fail so consistently, we must deconstruct the developmental misconceptions that drive them.
The data suggests that the greatest threat to the pediatric oral cavity is often the premature abdication of
parental responsibility, a phenomenon driven by a fundamental misunderstanding of physiological
readiness.
The Myth of Independence: Premature Autonomy in Preschoolers
A pervasive misconception in pediatric care is the belief that possession of a toothbrush equates to
effective hygiene (41). This assumption overlooks the biological constraints of neuromuscular

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development. The fine motor skills required to manipulate a toothbrush effectively, particularly the
dexterity needed for the rotatory or modified Bass technique to disrupt biofilm at the gingival margin,
do not fully mature until a child reaches approximately eight years of age (42). This developmental
milestone roughly coincides with the complex coordination required to tie shoelaces or write in cursive.
Consequently, prior to achieving this level of manual dexterity, a child’s brushing is often limited to
superficial scrubbing motions on accessible occlusal surfaces (43). This mechanical limitation leaves
the cervical margins and interproximal areas, the primary sites of ECC, completely untouched.
Therefore, the reliance on independent brushing in this demographic constitutes a fundamental error
where the complexity of the task exceeds the developmental capacity of the performer. Despite the
physiological necessity for adult intervention, the data indicates that supervision is frequently withdrawn
long before manual competence is achieved (44). It is crucial to understand that this accelerated
transition to independence is rarely an act of indifference. This phenomenon of premature autonomy is
not necessarily born of neglect, but often of necessity and socioeconomic pressure (45). In the Latin
American context, the "working parent" dynamic plays a significant role. The authors identify "working
mothers" and "large families" as plausible reasons for the inadequacy of parental supervision (46).
Parents often report an inability to provide individual attention due to time constraints, leading to a
delegation of hygiene duties to the child or older siblings who may lack the necessary motivation or
skill. This survival mode parenting relegates oral hygiene to the bottom of the priority list, effectively
transitioning the practice from a supervised health routine to a solitary chore performed by the child.
The consequences of this passive approach are not merely anecdotal but objectively quantifiable. The
study by Khan et al. provides robust statistical confirmation of this detachment, revealing through video
observation that 46% of parents were totally uninvolved during their child’s toothbrushing session (27).
In other words, the presence of a guiding parent was not merely an ancillary benefit but the definitive
determinant of whether biofilm was removed or retained. The data confirms that children who brush
under active verbal and hands-on supervision achieve significantly superior oral health status compared
to their unsupervised peers, proving that the biological barrier of motor unreadiness can only be
overcome through external adult regulation. This pervasive pattern of parental detachment is particularly
concerning when evaluated in light of the study’s structural equation modelling (PLS-SEM), which

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revealed a powerful counter-narrative regarding efficacy. The analysis demonstrated that parental
guidance served as the single most significant variable affecting plaque control, explaining 86% of the
variance (R2 = 0.86$) in the children’s plaque score change. In other words, the presence of a guiding
parent functioned as the definitive determinant of whether the biofilm was removed or retained (27).
Complementing these findings, Zhang et al. (2020) utilized structural equation modelling to demonstrate
that the mother’s own oral health behavior is a critical predictor of the child’s practice ( 𝛽 = 0.60). This
creates a cascading effect where the parent's attitude and socioeconomic status directly shape the
pediatric environment, confirming that the child's oral health cannot be treated in isolation from the
parental unit. Therefore, the recommendation for "supervision" must be radically redefined for the
pediatric consult (47). It is not sufficient for a parent to watch from the doorway or simply remind the
child to brush. "Active Supervision" must be interpreted as "Assisted Hygiene." This involves the parent
physically performing the brushing or finishing the job after the child has "practiced." The data supports
a hierarchy of involvement: parents who used a verbal and hands-on approach to assist their child were
scored highest in guidance and achieved better outcomes (48). We must coach parents to view
themselves not as spectators, but as the primary operators of the toothbrush until the child demonstrates
true manual competence.
To support this hands-on mandate, we must evaluate the physical tools at their disposal. If the parent is
the operator, the toothbrush is the instrument, and its design can either compound the difficulty of the
task or simplify the mechanics of plaque removal.
The Toothbrush: Manual vs. Electric
The selection of the hygiene instrument can partially mitigate the deficits in manual dexterity inherent
to this age group. While the vast majority of children in developing regions utilize manual
toothbrushes—67.3% in the Khan et al. study—the evidence suggests that technology offers a distinct
clinical advantage (27). Children utilizing electric toothbrushes exhibited superior oral health status,
specifically regarding plaque score reduction, gingival index, and dental caries status, compared to those
using manual counterparts (49). The mechanism for this advantage lies in the fact that electric
toothbrushes are less technique-sensitive, requiring significantly less manual dexterity to achieve
effective biofilm disruption (50). For a child with developing motor skills, or a parent struggling to brush

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a resisting toddler’s teeth, the electric toothbrush provides a compensatory efficacy (51). However, if a
manual brush remains the only option, the grip employed by the caregiver becomes critical. Khan et al.
identified that the "distal oblique grip" resulted in superior plaque removal compared to other grip types.
This specific hold allows the parent to manipulate the brush head with greater control, facilitating access
to posterior surfaces that are frequently missed by a standard power grip (52). No element of oral hygiene
is more critical, or more misunderstood, than the toothpaste itself (53). It acts as the topical vaccine
against caries, primarily through the chemotherapeutic action of fluoride (54). The concentration of this
agent is non-negotiable; Khan et al. demonstrated that using higher fluoride-containing toothpaste
(>1000 ppm) had a significant positive effect on dental caries status and plaque score change, whereas
lower concentrations often fail to provide the therapeutic remineralization required to arrest early lesions
(27). Furthermore, a persistent validity gap exists regarding quantity. While 35% of parents reported
using the recommended pea-sized amount, only 28% were observed doing so, with many using
insufficient amounts that limit therapeutic coverage. Finally, the most common error in home hygiene
remains the immediate water rinse (55). The study found that minimal post-brushing mouth rinsing
contributed significantly more to plaque reduction than multiple rinses (27). Current recommendations
emphasize that the water rinse essentially washes away the therapeutic agent before it has time to act;
therefore, the "Spit, Don't Rinse" rule is essential to retain the fluoride effect in the oral cavity. Finally,
we must address the mechanics of brushing. The horizontal or scrubbing technique is the most instinctive
for children and parents alike; Khan et al. observed that it was the preferred technique for 41.3% of
participants, explicably due to the lack of manual dexterity in this age group (27). While dental
professionals often preach the Modified Bass or rotatory techniques, these can be difficult for parents to
master on a moving child. Consequently, the data suggests that the systematic nature of the cleaning is
more vital than the specific stroke. Khan et al. found that a systematic toothbrushing sequence defined
by cleaning the arches in a predictable order contributed more to oral health than a non-systematic
approach. Children observed brushing in a non-systematic manner had poorer oral health, manifesting
specifically as localized gingivitis due to consistently missed areas. For the pediatrician, the advice to
parents should be distilled into three non-negotiable pillars of technical precision: 1) High Fluoride:
Ensure the toothpaste contains at least 1000 ppm fluoride. 2) No Rinse: Teach the child to spit the foam

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but never rinse with water immediately after. 3) Systematic Guidance: If using a manual brush, the
parent must use a distal oblique grip and follow a strict path around the mouth to ensure no surface is
neglected. The evidentiary basis for these protocols and the magnitude of the disparity between reported
and actual behavior are detailed below (Table 1).
Table 1: The Anatomy of Failure – Comparing Parental Perception, Observed Reality, and Clinical
Impact
Parameter
Reported Behavior
(Parental Claim)
Observed Reality (Video Evidence) Clinical Implication & Recommendation
I. BEHAVIORAL VALIDITY
Parental
Supervision
52% claimed
"Occasional Guidance"
11% showed active
involvement; 46% were totally
uninvolved.
Critical Deficit: Verbal/Hands-on supervision is
the #1 predictor of plaque removal ($R^2=0.86$).
Toothpaste Amount
35% claimed "Pea-
sized"
28% actually used "Pea-sized".
Safety: Risk of fluorosis (excess) or insufficient
active agent (deficit).
Fluoride Content
74% claimed usage of
specific pediatric pastes
(<1000 ppm)
50% matched the report;
significant confusion on
labeling.
Efficacy: Pastes with F > 1000 ppm are required
to significantly improve caries status.
Brushing Duration
40% claimed 30s – 1
min
51% brushed 1 – 2 mins
(Longer than reported).
Hawthorne Effect: Behavior improves under
observation; home duration is likely much shorter.
II. TECHNICAL PROFICIENCY
Instrument Type N/A 67.3% used Manual brushes.
Tooling: Electric brushes reduce technique sensitivity
and improve gingival indices.
Manual Grip Style N/A
Varied usage of Power vs. Precision
grips.
Technique: The Distal Oblique Grip is superior for
posterior plaque removal.
Rinsing Habit N/A
Frequent immediate water rinsing
observed.
Retention: Immediate rinsing washes away fluoride.
Adopt "Spit, Don't Rinse" protocol.
Motion Sequence N/A
41.3% used scrubbing; Random
sequencing common.
Coverage: Systematic sequencing (e.g., quadrant-by-
quadrant) prevents localized gingivitis.
Data derived from Khan et al. (2021) regarding discrepancies in pediatric oral hygiene practices (27).
However, the definition of these technical parameters serves little purpose if the mechanism of
knowledge transfer remains archaic. The persistence of the validity gap suggests that the error lies not
only in parental execution but in the pedagogical approach of the medical provider. Having established
what needs to be done, we must now critically evaluate how we have historically attempted to teach it.

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The Failure of Traditional Education
For decades, the standard of care in pediatric oral health education has relied upon passive dissemination
(56). Practitioners frequently distribute pamphlets at the conclusion of a vaccination visit or deliver a
brief verbal lecture to a distracted parent (57). Although well-intentioned, this traditional model
characterized by generic school lectures or rudimentary clinical instructions has proven insufficient to
alter behavior. The retention rate of such passive information is low, and the translation into daily habit
is even lower (58). In a region like Latin America, where health literacy varies significantly, we need a
pedagogical shift that moves from "telling" to "experiencing" (59).
To operationalize this pedagogical shift, the pediatric consultation must evolve from a bureaucratic
checkpoint into a diagnostic intervention. We propose a restructured clinical workflow that prioritizes
objective verification over subjective reporting. This protocol empowers the primary care physician to
dismantle the validity gap during the routine physical exam, ensuring that the "Dental Home" is
established not as an elective option but as an urgent developmental milestone (Table 2).
Table 2: Clinical Protocols for the Primary Care Physician
Protocol Actionable Step Scientific Rationale
1. Don't Just
Ask, Verify
Incorporate a Plaque Disclosing
Agent (swab or tablet) into the
physical exam to visualize
biofilm.
Anamnesis is diagnostically fragile due to
social desirability bias; parents frequently
misreport supervision levels and hygiene
quality. Objective visualization reveals the
"Validity Gap" between reported and actual
efficacy.
2. Prescribe
Fluoride
Explicitly write a prescription
for "Fluoridated Toothpaste
(>1000 ppm)" rather than
recommending generic
"toothpaste."
Parents often lack clarity on fluoride content.
Higher fluoride concentrations (>1000 ppm)
are statistically associated with significantly
better plaque score changes and caries status.
3. The "Lift the
Lip" Exam
Perform a quick inspection of
maxillary incisors at every
well-child visit starting at 6
months.
Early identification of demineralization allows
for intervention before cavitation occurs,
addressing the high prevalence of ECC.
4. Refer Early Establish the "Dental Home" by
age one.
Early preventive practices reduce the risk of
ECC and the burden on the family. Waiting
for pain or visible cavities is a failure of
prevention.
Once the clinical assessment is complete, the focus shifts to the domestic environment where the daily
battle against biofilm is waged. The complexity of the advice provided to caregivers must be reduced to

pág. 604
actionable non-negotiables that address the specific deficits in motor skills and supervision previously
identified. Central to this guidance is the "7-Year Rule," a developmental benchmark that aligns oral
hygiene supervision with the acquisition of fine motor skills such as tying shoelaces or cursive writing.
The following guidelines serve as a take-home roadmap for the parent to ensure mechanical efficacy is
maintained between visits.
Table 3: The "7-Year Rule" and Home Hygiene Guidelines for Parents
Guideline The Rule Why It Matters
1. You are the
Brusher
Active Supervision: You must
perform the brushing (preferably at
night) until the child can tie their
own shoelaces or write in cursive
(approx. age 7).
"Premature autonomy" is a primary risk
factor; 59% of preschoolers brush alone
despite lacking necessary motor skills.
Parental guidance is the strongest
predictor of plaque removal ().
2. The Right
Tools
Quantity: Use a "smear" (rice grain)
for <3 years; "pea-sized" for 3–6
years.
Technique: Spit, do not rinse with
water after brushing.
Using correct amounts minimizes
fluorosis risk while maximizing
protection. Minimal rinsing retains the
fluoride therapeutic effect on enamel.
3. Make it Fun
(Gamification)
Move from scolding to "simulation."
Use role-play ("you brush mine, I
brush yours"), songs, or apps.
Interactive, simulation-based education
significantly reduces adverse behaviors
(e.g., finger biting) and increases
cooperation compared to passive
instruction.
4. Nighttime is
Sacred
After the night brush, nothing but
water touches the teeth. No milk,
juice, or sweets.
Eliminating "bedtime sweetening
behavior" is critical to preventing caries in
the "First 1000 Days".
CONCLUSION
Reclaiming the Mouth as a Systemic Sentinel
The historical bifurcation of the body, which relegated the oral cavity to the periphery of pediatric
medicine, is no longer biologically or epidemiologically tenable. The evidence presented in this
manuscript confirms that the mouth is not merely an isolated anatomical structure but a sensitive
biological barometer acting as a mirror reflecting the child’s nutritional status, inflammatory burden,
and developmental trajectory. To ignore the oral cavity during the well-child visit is to ignore a

pág. 605
fundamental component of the "First 1000 Days" considering that this period is as critical for the
establishment of the oral microbiome as it is for neurological maturation.
However, recognizing the biological imperative is only the first step as we must also confront the
behavioral reality. The persistence of Early Childhood Caries despite high levels of reported parental
awareness exposes a profound "Validity Gap" in our traditional standard of care. We now understand
that parental knowledge does not equal mechanical competence. The data confirms that "Premature
Autonomy" defined as the abdication of hygiene duties to children who lack the neuro-motor maturity
to execute them serves as a primary driver of disease. A child who cannot tie their shoes cannot be
expected to disrupt biofilm effectively without adult intervention.
Therefore, the future of preventive pediatric care lies in the transition from passive information
dissemination to active behavioral coaching. The pediatrician must evolve from a mere interviewer into
a clinical auditor utilizing objective tools like plaque disclosing agents to visualize the invisible while
employing simulation techniques to transform abstract advice into physical skill. By enforcing the "7-
Year Rule" and establishing the Dental Home by age one, we empower the family to move from
intention to execution. Ultimately, by reclaiming the mouth as a systemic sentinel, we fulfill the true
promise of puericulture understood as the holistic cultivation of a child who is healthy not just in parts
but as a unified whole.
Funding
This work did not receive any specific grant from funding agencies in the public, commercial, or not-
for-profit sectors.
Acknowledgments
The authors would like to thank the Secretaría de Ciencia, Humanidades, Tecnología e Innovación
(SECIHTI) for the scholarship awarded to C.Z.O. (CVU 1320438).
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was not used in the creation of this manuscript.

pág. 606
Authors Contribution Statement
Conceptualization: J.A.S.P. and T.A.S.V.; Methodology and Data Analysis: J.A.S.P., H.C.S., and
A.H.A.; Investigation and Resources: H.C.S. and C.Z.O.; Writing – Original Draft Preparation:
J.A.S.P. and T.A.S.V.; Writing – Review & Editing: H.C.S., A.H.A., C.Z.O. and T.A.S.V.;
Visualization: G.F.N.T.; Supervision: T.A.S.V. All authors have read and agreed to the published
version of the manuscript.
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