Parental and individual determinants of dental trust in children: a path analysis of a conceptual model
Effective communication between a child and a dentist is fundamental to pediatric dental practice , impacting treatment outcomes and the overall dental experience . In pediatric dentistry, where child cooperation and comfort are crucial, a dentist’s ability to establish clear, empathetic, trust-based communication is essential . Trust encourages children to be more receptive to dental procedures and follow oral health recommendations . A strong trust relationship alleviates anxiety, fosters security, and enhances the child’s participation in oral health care . Emphasizing trust and effective communication is critical for ensuring productive dental visits, leading to better oral health outcomes and long-term child satisfaction . Children’s dental trust is shaped by various factors . The impact of the interaction between children and their families on their dental trust is significant . Understanding how both children’s and families’ oral and dental characteristics influence trust is crucial for developing effective strategies to enhance it. Therefore, a thorough examination of these factors is essential to foster stronger dental trust in children . This highlights the need for a comprehensive conceptual framework to systematically examine these factors and their impact on dental trust in children. Oral health literacy (OHL) plays a key role in communication between dentists and patients . Higher OHL levels in parents and children lead to better understanding and cooperation during dental visits . Parental oral health behaviors (OHBs) shape how children perceive and engage with dental care, fostering open and effective communication with dentists . Likewise, a child’s OHB, influenced by their parents, directly impacts their ability to follow dental advice and engage meaningfully with dentists . Children’s oral health-related quality of life (OHRQoL) is closely related to their comfort and confidence in dental settings , which can either facilitate or impede communication with the dentist . Dental anxiety is also crucial, as elevated anxiety levels can create communication barriers , making it challenging for dentists to explain procedures and for children to express concerns or discomfort . Conversely, high levels of dental trust can significantly enhance communication . Trust in children plays a clinically significant role in pediatric dentistry and dental research . Understanding how various determinants interact with dental trust is essential for designing effective interventions that enhance trust and improve children’s dental care experiences. However, research applying these models in the context of pediatric dental trust is limited. This study proposes a conceptual model that outlines the relationships between dental trust in children and endogenous variables (e.g., children’s OHBs, parental OHBs, child dental anxiety, and child OHRQoL) and exogenous variables (e.g., oral health literacy). Path analysis is a statistical technique used to examine directed relationships among a set of variables, allowing researchers to test complex models by evaluating both direct and indirect effects. It provides insights into how variables influence one another within a conceptual framework, highlighting the pathways through which certain factors impact outcomes. This study aimed to develop and test a conceptual model to explore the pathways linking parental and individual determinants of dental trust in children. Additionally, this study aimed to identify which parental and individual variables were most strongly associated with dental trust among children.   Study design Ethical approval for this study was obtained from the Health Ethics Committee of Sivas Cumhuriyet University, Turkey (ID: 2023-04/07). This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Informed consent was obtained from all participating children and their parents or guardians before their involvement in the study. This study employed a cross-sectional observational design. The study group consisted of children and their parents who visited the Department of Pediatric Dentistry at the Faculty of Dentistry, Sivas Cumhuriyet University. Participants were initially selected through convenience sampling based on clinic attendance, followed by random selection to ensure a representative sample. The sample size was calculated based on a desired power (1-β error probability) of 0.90, a significance level of 0.05, a confidence interval of 95%, and an effect size of 0.8. The minimum number of participants required for this study was 260. The sample was increased to 312 parent-child dyads to account for possible exclusions and dropouts. The inclusion criteria for the study were as follows: (a) children aged 7–12 years who were healthy, along with their parents, (b) children who were cooperative during dental examinations, and (c) parents who were capable of completing a questionnaire in Turkish. Children and parents who did not meet these criteria or were unwilling to participate voluntarily were excluded. Path model development A thorough literature review was conducted to develop a path model. Search terms such as “Dental Trust,” “Oral Health Literacy,” “Oral Health-Related Quality of Life,” and “Dental Anxiety” were searched across databases such as Google Scholar, PubMed, and Web of Science, and relevant publications were categorized. The search was limited to peer-reviewed English journal publications to ensure the inclusion of relevant high-quality studies. A draft of the conceptual model was prepared based on the data obtained from the literature review and insights from previous models . To establish face validity, the draft model was sent to an expert team of lecturers from the Department of Pediatric Dentistry and Biostatistics. The experts were asked to evaluate the appropriateness of the endogenous and exogenous variables included in the conceptual model as well as the proposed pathways between them. Based on their feedback, the model was revised and finalized to ensure that it accurately reflected the theoretical constructs and relationships. The path model tested in this study is shown in Fig. . This model included one exogenous latent variable (oral health literacy) and five endogenous variables (parental OHBs, child OHBs, child dental anxiety levels, OHRQoL, and dental trust). Measurement The children and their parents were initially assessed by the researcher for eligibility. Parent-child pairs who met the inclusion criteria were provided with detailed information about the study. During the first session, noninvasive preventive dental procedures were performed by the primary researcher, and a follow-up appointment was scheduled. At the beginning of the second session, a trained and experienced dental assistant who was not involved in the study administered the data collection forms to the participants. The following scales and forms were used for data collection: (a) a sociodemographic data form; (b) the Dental Trust Scale (DTS) (c) the Turkish version of the Oral Health Literacy Assessment Task (TOHLAT-P); (d) the Dental Subscale of the Children’s Fear Survey Schedule (CFSS-DS); (e) the Early Childhood Oral Health Impact Scale (ECOHIS); and (f) the OHB Form. The sociodemographic variables collected included age, sex, parental education level, monthly income, and health insurance status. Endogenous variables Dental trust Dental trust was assessed using the DTS , which was adapted for the Turkish language . The DTS comprises 11 items designed to measure trust in dentists. Responses were given on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” Higher scores indicate a higher level of trust in the dentist. Parental OHBs Parental OHBs were assessed using a previously validated and reliable OHB form . Parents were asked to respond to questions in the survey regarding their educational level, income status, health insurance coverage, frequency of tooth brushing, frequency of dental visits, date of their most recent dental visit, any negative experiences during previous dental visits, and whether they had previously received information on oral and dental health. Child OHBs This variable was assessed using a previously validated and reliable form for OHB , which includes questions on the frequency of tooth brushing, regularity of dental visits, time elapsed since the last dental appointment, experiences with negative dental events, and frequency and timing of consuming cariogenic foods. Each item is scored on a scale where “1” represents the most unfavorable response, with progressively higher scores reflecting more positive behaviors. The total possible scores range from 5 to 16, with higher scores indicating better oral health practices. OHRQoL The ECOHIS was used to assess OHRQoL. The Turkish version of this scale has been previously validated and found reliable . The ECOHIS consists of 13 questions administered to parents of children, with each question offering six response options. The first nine questions evaluate the effects of dental problems and treatments on children’s daily activities, such as eating, drinking, and communication. The second section includes the remaining four questions and assesses the impact of children’s dental problems and treatment on family members. Parents responded to each question by selecting one of six options rated on a scale of 0 to 5 (0 = never, 1 = hardly ever, 2 = occasionally, 3 = often, 4 = very often, and 5 = do not know). This scoring system results in a total score ranging from 0 to 52, with higher scores indicating a greater presence of negative impacts and a deterioration in OHRQoL. CFSS-DS The level of dental anxiety in the children was assessed using the CFSS-DS. The CFSS-DS consists of 15 items, and its Turkish validity and reliability have been established . Children responded to each item on a scale of 1–5, with the following options: 1 = not afraid, 2 = slightly afraid, 3 = moderately afraid, 4 = very afraid, and 5 = extremely afraid. For younger children or those unable to read and answer the questions themselves, the parents completed the scale on their behalf. The total score ranges from 15 to 75, with higher scores indicating higher levels of anxiety. Exogenous latent variable Parental oral health literacy Parental oral health literacy was assessed using the TOHLAT-P. Originally developed in English and Chinese, the TOHLAT-P has been adapted for Turkish . This scale specifically measures oral health literacy in pediatric dentistry and consists of three sections. In the first section (recognizing and labeling), participants are shown images of their teeth and asked to identify the marked areas. The second section (numeracy/literacy) includes four questions requiring numerical analysis in which participants have to read the instructions and answer accordingly. The final section (closed/organized) involves a matching test. Scale scores range from 0 to 52, with higher scores indicating a higher level of oral health literacy. Study hypotheses The following four a priori hypotheses were formulated: Dental Trust = (β1⋅Parental Oral Health Literacy) + (β2⋅Child OHBs) + (β3⋅Child OHRQoL) + (β4⋅Child Dental Anxiety). Child OHBs = (β5⋅Parental OHBs). Child Dental Anxiety = (β6⋅Parental OHBs). Child OHRQoL = (β7⋅Child Dental Anxiety) + (β8⋅Child OHBs). Statistical analysis SPSS and AMOS software (IBM SPSS Statistics for Windows, version 22; Armonk, NY, USA) were used for data analysis. Because the assumptions for the parametric tests were not met (as determined by the Kolmogorov-Smirnov test), the Mann-Whitney U test was used to compare measurements between two independent groups, and the Kruskal-Wallis test was employed to compare measurements across more than two independent groups. When significant differences were found, post-hoc Mann-Whitney U tests were conducted to identify the specific group(s) responsible for the differences. Data are presented as arithmetic means, medians, minimum and maximum values, frequencies, and percentages. Statistical significance was set at p < 0.05. Structural equation modeling (SEM) and path analysis were conducted to validate the conceptual model. To assess the homogeneity of the continuous variable distributions, skewness and kurtosis values were calculated. Model fit was evaluated using several indices, including root mean square error of approximation (RMSEA), Tucker-Lewis index (TLI), comparative fit index (CFI), adjusted goodness of fit index (AGFI), incremental fit index (IFI), standardized root mean square residual (SRMR), the chi-square statistic (χ²), degrees of freedom (df), and the χ²/df ratio. The following criteria were used to determine a good model fit: χ²/df ≤ 3, P -value (for the chi-square test) > 0.05, GFI, IFI, and TLI > 0.95, CFI and AGFI > 0.90, and RMSEA and SRMR < 0.08 .   Ethical approval for this study was obtained from the Health Ethics Committee of Sivas Cumhuriyet University, Turkey (ID: 2023-04/07). This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Informed consent was obtained from all participating children and their parents or guardians before their involvement in the study. This study employed a cross-sectional observational design. The study group consisted of children and their parents who visited the Department of Pediatric Dentistry at the Faculty of Dentistry, Sivas Cumhuriyet University. Participants were initially selected through convenience sampling based on clinic attendance, followed by random selection to ensure a representative sample. The sample size was calculated based on a desired power (1-β error probability) of 0.90, a significance level of 0.05, a confidence interval of 95%, and an effect size of 0.8. The minimum number of participants required for this study was 260. The sample was increased to 312 parent-child dyads to account for possible exclusions and dropouts. The inclusion criteria for the study were as follows: (a) children aged 7–12 years who were healthy, along with their parents, (b) children who were cooperative during dental examinations, and (c) parents who were capable of completing a questionnaire in Turkish. Children and parents who did not meet these criteria or were unwilling to participate voluntarily were excluded.   A thorough literature review was conducted to develop a path model. Search terms such as “Dental Trust,” “Oral Health Literacy,” “Oral Health-Related Quality of Life,” and “Dental Anxiety” were searched across databases such as Google Scholar, PubMed, and Web of Science, and relevant publications were categorized. The search was limited to peer-reviewed English journal publications to ensure the inclusion of relevant high-quality studies. A draft of the conceptual model was prepared based on the data obtained from the literature review and insights from previous models . To establish face validity, the draft model was sent to an expert team of lecturers from the Department of Pediatric Dentistry and Biostatistics. The experts were asked to evaluate the appropriateness of the endogenous and exogenous variables included in the conceptual model as well as the proposed pathways between them. Based on their feedback, the model was revised and finalized to ensure that it accurately reflected the theoretical constructs and relationships. The path model tested in this study is shown in Fig. . This model included one exogenous latent variable (oral health literacy) and five endogenous variables (parental OHBs, child OHBs, child dental anxiety levels, OHRQoL, and dental trust).   The children and their parents were initially assessed by the researcher for eligibility. Parent-child pairs who met the inclusion criteria were provided with detailed information about the study. During the first session, noninvasive preventive dental procedures were performed by the primary researcher, and a follow-up appointment was scheduled. At the beginning of the second session, a trained and experienced dental assistant who was not involved in the study administered the data collection forms to the participants. The following scales and forms were used for data collection: (a) a sociodemographic data form; (b) the Dental Trust Scale (DTS) (c) the Turkish version of the Oral Health Literacy Assessment Task (TOHLAT-P); (d) the Dental Subscale of the Children’s Fear Survey Schedule (CFSS-DS); (e) the Early Childhood Oral Health Impact Scale (ECOHIS); and (f) the OHB Form. The sociodemographic variables collected included age, sex, parental education level, monthly income, and health insurance status. Endogenous variables Dental trust Dental trust was assessed using the DTS , which was adapted for the Turkish language . The DTS comprises 11 items designed to measure trust in dentists. Responses were given on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” Higher scores indicate a higher level of trust in the dentist. Parental OHBs Parental OHBs were assessed using a previously validated and reliable OHB form . Parents were asked to respond to questions in the survey regarding their educational level, income status, health insurance coverage, frequency of tooth brushing, frequency of dental visits, date of their most recent dental visit, any negative experiences during previous dental visits, and whether they had previously received information on oral and dental health. Child OHBs This variable was assessed using a previously validated and reliable form for OHB , which includes questions on the frequency of tooth brushing, regularity of dental visits, time elapsed since the last dental appointment, experiences with negative dental events, and frequency and timing of consuming cariogenic foods. Each item is scored on a scale where “1” represents the most unfavorable response, with progressively higher scores reflecting more positive behaviors. The total possible scores range from 5 to 16, with higher scores indicating better oral health practices. OHRQoL The ECOHIS was used to assess OHRQoL. The Turkish version of this scale has been previously validated and found reliable . The ECOHIS consists of 13 questions administered to parents of children, with each question offering six response options. The first nine questions evaluate the effects of dental problems and treatments on children’s daily activities, such as eating, drinking, and communication. The second section includes the remaining four questions and assesses the impact of children’s dental problems and treatment on family members. Parents responded to each question by selecting one of six options rated on a scale of 0 to 5 (0 = never, 1 = hardly ever, 2 = occasionally, 3 = often, 4 = very often, and 5 = do not know). This scoring system results in a total score ranging from 0 to 52, with higher scores indicating a greater presence of negative impacts and a deterioration in OHRQoL. CFSS-DS The level of dental anxiety in the children was assessed using the CFSS-DS. The CFSS-DS consists of 15 items, and its Turkish validity and reliability have been established . Children responded to each item on a scale of 1–5, with the following options: 1 = not afraid, 2 = slightly afraid, 3 = moderately afraid, 4 = very afraid, and 5 = extremely afraid. For younger children or those unable to read and answer the questions themselves, the parents completed the scale on their behalf. The total score ranges from 15 to 75, with higher scores indicating higher levels of anxiety. Exogenous latent variable Parental oral health literacy Parental oral health literacy was assessed using the TOHLAT-P. Originally developed in English and Chinese, the TOHLAT-P has been adapted for Turkish . This scale specifically measures oral health literacy in pediatric dentistry and consists of three sections. In the first section (recognizing and labeling), participants are shown images of their teeth and asked to identify the marked areas. The second section (numeracy/literacy) includes four questions requiring numerical analysis in which participants have to read the instructions and answer accordingly. The final section (closed/organized) involves a matching test. Scale scores range from 0 to 52, with higher scores indicating a higher level of oral health literacy.   Dental trust Dental trust was assessed using the DTS , which was adapted for the Turkish language . The DTS comprises 11 items designed to measure trust in dentists. Responses were given on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” Higher scores indicate a higher level of trust in the dentist. Parental OHBs Parental OHBs were assessed using a previously validated and reliable OHB form . Parents were asked to respond to questions in the survey regarding their educational level, income status, health insurance coverage, frequency of tooth brushing, frequency of dental visits, date of their most recent dental visit, any negative experiences during previous dental visits, and whether they had previously received information on oral and dental health. Child OHBs This variable was assessed using a previously validated and reliable form for OHB , which includes questions on the frequency of tooth brushing, regularity of dental visits, time elapsed since the last dental appointment, experiences with negative dental events, and frequency and timing of consuming cariogenic foods. Each item is scored on a scale where “1” represents the most unfavorable response, with progressively higher scores reflecting more positive behaviors. The total possible scores range from 5 to 16, with higher scores indicating better oral health practices. OHRQoL The ECOHIS was used to assess OHRQoL. The Turkish version of this scale has been previously validated and found reliable . The ECOHIS consists of 13 questions administered to parents of children, with each question offering six response options. The first nine questions evaluate the effects of dental problems and treatments on children’s daily activities, such as eating, drinking, and communication. The second section includes the remaining four questions and assesses the impact of children’s dental problems and treatment on family members. Parents responded to each question by selecting one of six options rated on a scale of 0 to 5 (0 = never, 1 = hardly ever, 2 = occasionally, 3 = often, 4 = very often, and 5 = do not know). This scoring system results in a total score ranging from 0 to 52, with higher scores indicating a greater presence of negative impacts and a deterioration in OHRQoL. CFSS-DS The level of dental anxiety in the children was assessed using the CFSS-DS. The CFSS-DS consists of 15 items, and its Turkish validity and reliability have been established . Children responded to each item on a scale of 1–5, with the following options: 1 = not afraid, 2 = slightly afraid, 3 = moderately afraid, 4 = very afraid, and 5 = extremely afraid. For younger children or those unable to read and answer the questions themselves, the parents completed the scale on their behalf. The total score ranges from 15 to 75, with higher scores indicating higher levels of anxiety.   Dental trust was assessed using the DTS , which was adapted for the Turkish language . The DTS comprises 11 items designed to measure trust in dentists. Responses were given on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” Higher scores indicate a higher level of trust in the dentist.   Parental OHBs were assessed using a previously validated and reliable OHB form . Parents were asked to respond to questions in the survey regarding their educational level, income status, health insurance coverage, frequency of tooth brushing, frequency of dental visits, date of their most recent dental visit, any negative experiences during previous dental visits, and whether they had previously received information on oral and dental health.   This variable was assessed using a previously validated and reliable form for OHB , which includes questions on the frequency of tooth brushing, regularity of dental visits, time elapsed since the last dental appointment, experiences with negative dental events, and frequency and timing of consuming cariogenic foods. Each item is scored on a scale where “1” represents the most unfavorable response, with progressively higher scores reflecting more positive behaviors. The total possible scores range from 5 to 16, with higher scores indicating better oral health practices.   The ECOHIS was used to assess OHRQoL. The Turkish version of this scale has been previously validated and found reliable . The ECOHIS consists of 13 questions administered to parents of children, with each question offering six response options. The first nine questions evaluate the effects of dental problems and treatments on children’s daily activities, such as eating, drinking, and communication. The second section includes the remaining four questions and assesses the impact of children’s dental problems and treatment on family members. Parents responded to each question by selecting one of six options rated on a scale of 0 to 5 (0 = never, 1 = hardly ever, 2 = occasionally, 3 = often, 4 = very often, and 5 = do not know). This scoring system results in a total score ranging from 0 to 52, with higher scores indicating a greater presence of negative impacts and a deterioration in OHRQoL.   The level of dental anxiety in the children was assessed using the CFSS-DS. The CFSS-DS consists of 15 items, and its Turkish validity and reliability have been established . Children responded to each item on a scale of 1–5, with the following options: 1 = not afraid, 2 = slightly afraid, 3 = moderately afraid, 4 = very afraid, and 5 = extremely afraid. For younger children or those unable to read and answer the questions themselves, the parents completed the scale on their behalf. The total score ranges from 15 to 75, with higher scores indicating higher levels of anxiety.   Parental oral health literacy Parental oral health literacy was assessed using the TOHLAT-P. Originally developed in English and Chinese, the TOHLAT-P has been adapted for Turkish . This scale specifically measures oral health literacy in pediatric dentistry and consists of three sections. In the first section (recognizing and labeling), participants are shown images of their teeth and asked to identify the marked areas. The second section (numeracy/literacy) includes four questions requiring numerical analysis in which participants have to read the instructions and answer accordingly. The final section (closed/organized) involves a matching test. Scale scores range from 0 to 52, with higher scores indicating a higher level of oral health literacy.   Parental oral health literacy was assessed using the TOHLAT-P. Originally developed in English and Chinese, the TOHLAT-P has been adapted for Turkish . This scale specifically measures oral health literacy in pediatric dentistry and consists of three sections. In the first section (recognizing and labeling), participants are shown images of their teeth and asked to identify the marked areas. The second section (numeracy/literacy) includes four questions requiring numerical analysis in which participants have to read the instructions and answer accordingly. The final section (closed/organized) involves a matching test. Scale scores range from 0 to 52, with higher scores indicating a higher level of oral health literacy.   The following four a priori hypotheses were formulated: Dental Trust = (β1⋅Parental Oral Health Literacy) + (β2⋅Child OHBs) + (β3⋅Child OHRQoL) + (β4⋅Child Dental Anxiety). Child OHBs = (β5⋅Parental OHBs). Child Dental Anxiety = (β6⋅Parental OHBs). Child OHRQoL = (β7⋅Child Dental Anxiety) + (β8⋅Child OHBs).   SPSS and AMOS software (IBM SPSS Statistics for Windows, version 22; Armonk, NY, USA) were used for data analysis. Because the assumptions for the parametric tests were not met (as determined by the Kolmogorov-Smirnov test), the Mann-Whitney U test was used to compare measurements between two independent groups, and the Kruskal-Wallis test was employed to compare measurements across more than two independent groups. When significant differences were found, post-hoc Mann-Whitney U tests were conducted to identify the specific group(s) responsible for the differences. Data are presented as arithmetic means, medians, minimum and maximum values, frequencies, and percentages. Statistical significance was set at p < 0.05. Structural equation modeling (SEM) and path analysis were conducted to validate the conceptual model. To assess the homogeneity of the continuous variable distributions, skewness and kurtosis values were calculated. Model fit was evaluated using several indices, including root mean square error of approximation (RMSEA), Tucker-Lewis index (TLI), comparative fit index (CFI), adjusted goodness of fit index (AGFI), incremental fit index (IFI), standardized root mean square residual (SRMR), the chi-square statistic (χ²), degrees of freedom (df), and the χ²/df ratio. The following criteria were used to determine a good model fit: χ²/df ≤ 3, P -value (for the chi-square test) > 0.05, GFI, IFI, and TLI > 0.95, CFI and AGFI > 0.90, and RMSEA and SRMR < 0.08 .   Overall, 312 participants completed the forms; however, 45 were excluded because of incomplete data. Consequently, 267 children aged 7 to 12 years (mean age 9.14 ± 1.63) were included in the final analysis. A positive correlation was observed between age and total dental trust scores, although this was not significant ( r = 0.083, p = 0.175). Of the children included in the study, 142 were girls (53.2%). There was no significant difference in total dental trust scores between the sexes ( p = 0.800). Path analysis The goodness-of-fit indices obtained from the confirmatory factor analysis (CFA) conducted to test the fit of the path model are presented in Fig. legends. The fit indices for the model demonstrated excellent agreement with the values recommended in the literature, indicating that the fit of the model was highly satisfactory. (a) As parental oral health literacy increased, a positive increase in parental OHBs was observed (β = 0.06; p < 0.001). (b) There was a positive increase in child OHBs as parental OHBs improved (β = 0.33; p < 0.001). (c) As parental OHBs improved, child dental anxiety levels decreased (β = -0.15; p < 0.001). (d) A reduction in child dental anxiety levels was associated with a positive increase in child OHRQoL (β = 0.25; p < 0.001). (e) As child OHBs improved, a positive increase in OHRQoL was observed (β = 0.26; p < 0.001). (f) An increase in child OHBs was associated with increased dental trust scores (β = 0.13; p < 0.001). (g) A reduction in child dental anxiety levels was associated with an increase in child dental trust scores (β = -0.18; p < 0.001). (h) As child OHRQoL improved, dental trust scores increased (β = 0.15; p < 0.001). Table presents the direct, indirect, and total effects of the variables tested in the path model. Variables with the most significant direct effects on children’s dental trust were parental oral health literacy and child dental anxiety. Parental oral health literacy positively influenced dental trust, whereas child dental anxiety had a negative effect. Among the components of parental oral health literacy, mathematical skills had the highest positive impact on overall parental oral health literacy. The most significant indirect effect was found between parental OHBs and child OHRQoL, with a positive influence. Descriptive data on child OHBs and a comparative analysis of dental trust scores are summarized in Table . The analysis indicated no significant differences in the total dental trust scores across the examined variables ( p > 0.05). Table presents the distribution and comparison of the sociodemographic characteristics and OHBs of parents of participating children concerning dental trust scores. Among the variables analyzed, “education level” and “income” demonstrated significant differences ( p < 0.05), while no significant differences were observed for the other variables ( p > 0.05). There was a significant difference in the analysis of parental education level concerning total dental trust scores ( p < 0.05). Post hoc pairwise comparisons revealed that the “primary school” group differed significantly from the other educational groups. Additionally, there was a significant difference in the comparison of health insurance status with total dental trust scores ( p < 0.05), particularly between the “no insurance” group and the other insurance status groups.   The goodness-of-fit indices obtained from the confirmatory factor analysis (CFA) conducted to test the fit of the path model are presented in Fig. legends. The fit indices for the model demonstrated excellent agreement with the values recommended in the literature, indicating that the fit of the model was highly satisfactory. (a) As parental oral health literacy increased, a positive increase in parental OHBs was observed (β = 0.06; p < 0.001). (b) There was a positive increase in child OHBs as parental OHBs improved (β = 0.33; p < 0.001). (c) As parental OHBs improved, child dental anxiety levels decreased (β = -0.15; p < 0.001). (d) A reduction in child dental anxiety levels was associated with a positive increase in child OHRQoL (β = 0.25; p < 0.001). (e) As child OHBs improved, a positive increase in OHRQoL was observed (β = 0.26; p < 0.001). (f) An increase in child OHBs was associated with increased dental trust scores (β = 0.13; p < 0.001). (g) A reduction in child dental anxiety levels was associated with an increase in child dental trust scores (β = -0.18; p < 0.001). (h) As child OHRQoL improved, dental trust scores increased (β = 0.15; p < 0.001). Table presents the direct, indirect, and total effects of the variables tested in the path model. Variables with the most significant direct effects on children’s dental trust were parental oral health literacy and child dental anxiety. Parental oral health literacy positively influenced dental trust, whereas child dental anxiety had a negative effect. Among the components of parental oral health literacy, mathematical skills had the highest positive impact on overall parental oral health literacy. The most significant indirect effect was found between parental OHBs and child OHRQoL, with a positive influence. Descriptive data on child OHBs and a comparative analysis of dental trust scores are summarized in Table . The analysis indicated no significant differences in the total dental trust scores across the examined variables ( p > 0.05). Table presents the distribution and comparison of the sociodemographic characteristics and OHBs of parents of participating children concerning dental trust scores. Among the variables analyzed, “education level” and “income” demonstrated significant differences ( p < 0.05), while no significant differences were observed for the other variables ( p > 0.05). There was a significant difference in the analysis of parental education level concerning total dental trust scores ( p < 0.05). Post hoc pairwise comparisons revealed that the “primary school” group differed significantly from the other educational groups. Additionally, there was a significant difference in the comparison of health insurance status with total dental trust scores ( p < 0.05), particularly between the “no insurance” group and the other insurance status groups.   This study developed and tested a conceptual model to understand the relationship between dental trust in children and several variables, including children’s OHBs, dental anxiety, OHRQoL, and parental oral health literacy. These findings confirmed the hypothesized pathways, showing that improved parental oral health literacy positively influences parental and child OHBs, which, in turn, enhances dental trust in children. Additionally, lower levels of dental anxiety and better OHRQoL in children were associated with higher dental trust scores. One of the major strengths of this study was its methodological design. SEM and path analysis allowed for the simultaneous assessment of multiple relationships within the conceptual model, providing a comprehensive understanding of the complex interactions between variables . Another advantage of using SEM in this study is its ability to account for measurement error, which enhances the accuracy of the estimated relationships between variables. This feature is particularly valuable when analyzing complex models, as it provides more reliable and nuanced insights into how factors like oral health literacy and dental anxiety influence trust in pediatric dentistry. The model’s fit indices indicated strong alignment with the theoretical constructions, suggesting that the model was well-suited for testing the proposed hypotheses. Path analysis offers advantages over correlation analysis, particularly because correlation does not allow for examining the mediating role of a third variable in the relationship between two variables . This study had some limitations. First, the cross-sectional design limited the ability to infer causality between variables. However, this study focused on exploring the relationships between the variables rather than their prevalence, with the strength of the analyses grounded in statistical assumptions regarding the distribution of the variables. Second, using self-reported measures to assess OHBs and literacy could introduce a response bias. Another limitation is the inclusion of several individual variables, excluding parental and environmental factors. Additionally, the study was conducted in a single geographic location within a specific cultural context, which may limit the generalizability of the findings to other populations. Future research should consider longitudinal designs and diverse samples. Parental oral health literacy has consistently been recognized as a critical factor in shaping children’s health behaviors and outcomes . In this study, higher oral health literacy positively influenced both parental and child OHBs, consistent with the previous studies  which reported that higher parental literacy was associated with more frequent dental visits and better oral hygiene practices in children. These findings are also consistent with previously published models  showing that parental behaviors are significant predictors of children’s oral health and anxiety levels. These studies emphasize the role of the family environment in influencing children’s responses to dental care, particularly regarding how parental attitudes and behaviors can either reduce or exacerbate dental anxiety in children. The findings of this study reinforce the critical influence of parental behavior on pediatric dental outcomes and support the idea that effective parental involvement is essential for pediatric dental care . Another aspect of this study is its focus on dental trust as a distinct outcome variable, which has not been widely modeled in previous research. While previous studies have examined the impact of dental anxiety on OHBs , few  have specifically explored the pathways leading to trust in the dental context, especially in pediatric settings. This study has the potential to fill this gap by demonstrating that dental trust is not only influenced by child-related factors such as anxiety and OHRQoL but is also significantly shaped by parental literacy and behaviors. The negative impact of dental anxiety on trust scores observed in this study is consistent with the previous studies which reported that higher levels of dental anxiety are linked to reduced trust in dentists , resulting in poorer cooperation during dental procedures . This highlights the importance of addressing dental anxiety to build and maintain trust, which is essential for successful dental interventions. Furthermore, the current study extends this understanding by showing that reducing anxiety can improve OHRQoL, enhance dental trust, and emphasize the interconnectedness of these factors. Compared with earlier models , this study introduced OHRQoL as a mediator between children’s OHBs and dental trust. Previous studies  have reported that quality of life plays a significant role in dental settings; however, this study provides empirical evidence of its importance in developing trust in pediatric dentistry. This suggests that interventions to improve children’s overall dental experience could lead to enhanced trust and better long-term outcomes. Children whose parents maintain regular oral hygiene and dental visit routines are more likely to adopt similar behaviors , suggesting an intergenerational transmission of health practices. The findings support this view as they directly link these behaviors to the development of dental trust, offering a more integrated view of how family dynamics contribute to children’s dental experiences. Overall, while this study corroborates many findings from previous research , it expands our understanding of pediatric dental trust by integrating multiple determinants into a comprehensive model. This approach not only validates the significance of known factors such as anxiety and oral health literacy but also introduces new variables such as OHRQoL, providing a holistic perspective on how trust is built and sustained in pediatric dental care. Parental oral health literacy closely link to children’s OHBs. Vann et al.  reported that parents with higher oral health literacy tended to promote better oral hygiene practices in their children, leading to improved oral health outcomes. The current study showed that higher levels of parental oral health literacy directly enhanced both parental and child OHBs, subsequently increasing dental trust among children. Previous studies  have also emphasized the significant role that parental influence plays in shaping children’s OHBs. The current study found that when children consistently practiced good oral hygiene, their trust in dental professionals strengthened, likely due to the reduced incidence of negative dental experiences. Child dental anxiety is a significant barrier to developing trust in dental care , and higher anxiety levels are correlated with reduced trust and increased avoidance behaviors . The current study also supports previous studies showing that lower levels of dental anxiety are associated with higher dental trust scores among children , suggesting that effective anxiety management strategies can enhance the overall dental experience of children and foster long-term trust in dental practitioners. Moreover, our findings align with the conclusions of Locker et al. , who reported that improvements in OHRQoL are linked to increased dental trust. Based on the model findings, future interventions could focus on enhancing parental oral health literacy and addressing dental anxiety through targeted educational programs and anxiety-reducing strategies. Such interventions could foster greater trust in pediatric dental settings, ultimately promoting more positive oral health outcomes in children. This approach bridges our findings with actionable strategies, providing practical applications for improving pediatric dental care. This study provides a validated model to elucidate the pathways through which parental and individual factors influence dental trust in children. The findings suggest that enhancing parental oral health literacy and addressing children’s dental anxiety could be effective in improving dental trust and, consequently, oral health outcomes in the pediatric population. The findings indicate that focusing on parental education and child anxiety management within clinical settings could strengthen dental trust, supporting more positive dental experiences and healthier oral habits in children. Future studies should explore the longitudinal effects of these interventions and apply these models to diverse populations to enhance their generalizability. The findings of this study are significant for pediatric dental practitioners, as they highlight the need for targeted educational and behavioral interventions to build and maintain dental trust in young patients.   