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doi:10.1111/jpc.12469
VIEWPOINT
Preventing dental decay in young children requires all primary health care professionals to work together Anthony Blinkhorn1 and Fiona Blinkhorn2 1
Faculty of Dentistry, University of Sydney, Sydney and 2Faculty of Health, School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia
Untreated dental caries causes pain and suffering to children, as well as stress to the family.1 Young children with dental pain are difficult to treat and may require a general anaesthetic in hospital to receive dental care. This is expensive, carries a risk of death, can cause postoperative pain and treatment usually entails multiple dental extractions.2 Long wait lists for treatment of this type often means that young children can suffer pain and loss of sleep for over 12 months.3 Child and family nurses working in Western Sydney, New South Wales considered dental caries in young children to be one of the most significant issues in their daily working lives, especially in areas with large multicultural populations.4 Unlike many childhood health problems, dental caries is preventable with simple behavioural changes.5 The important health messages for families with pre-school children are: 1 Do not put a child to bed with a night time bottle once the baby teeth have begun to erupt.6 2 Do not allow a child to have sugar-containing drinks from a feeding bottle. 3 Restrict sugary foods and drinks to meal times, and drink fluoridated water.7 4 Brush the teeth gently twice a day with a smear of fluoride toothpaste.8,9 If these behaviours are implemented, then all young children should have healthy teeth. Unfortunately, in many socially disadvantaged areas of the city of Sydney, there is a tendency to: • Provide sweetened milk in night time bottles • Use sugar containing drinks as comforters for long periods of time during the day • Brush their child’s teeth infrequently10 As a result, their children may suffer an aggressive form of tooth decay termed early childhood caries, which destroys the primary dentition over a relatively short period of time. An education programme to help families improve the dental health of their young children is offered in the Paediatric Dental Department at Westmead Centre for Oral Health. The target group was those families with a child under 5 years of age waiting for dental treatment under general anaesthesia. Many
Correspondence: Professor Anthony Blinkhorn, Faculty of Dentistry, University of Sydney, 1 Mons Road, Westmead, NSW 2145, Australia. Fax: 61 2 88214370; email: [email protected] Conflict of interest: The authors declare no conflict of interest with this paper. Accepted for publication 24 October 2013.
of them were from non-English speaking backgrounds and had limited contact with dental care professionals. The programme emphasised the following key messages: 1 Parents/carer’s should supervise and help their children brush their teeth twice daily with a fluoride toothpaste. 2 Sugary drinks should only be given at meal times and never in a feeding bottle. 3 Children should not use a bottle at night as a comforter. In order to encourage the appropriate behaviour, free toothpaste, toothbrushes, diet advice leaflets and ‘sippy’ training cups were supplied. The programme proved very popular with dental staff as they were pleased to be focusing on preventive care, and the children enjoyed the experience and wanted to return for more visits. As part of the evaluation process, parents were asked to comment on the programme through a semi-structured interview. Three main themes were identified from the collected data: • Value of the setting • Difficulties in controlling diet • Overall assessment of the programme
Value of the Setting The advice programme was given in the Paediatric Dental Department at Westmead Centre for Oral Health. There were complaints about car parking, crowded waiting areas, having to travel to receive advice and taking time off work. However, the parents were prepared to ignore these difficulties as they held the dental team in high regard, valued the assessments and their children enjoyed the visits so anxiety was reduced and they thought the practical tooth brushing lessons were very helpful. Tooth brushing with fluoride toothpaste became a routine for all the family, and parents reported a reduction in their child’s dental pain. Having the teeth checked was particularly popular, as parents wanted the mouth monitored, as they felt unsure about whether the preventive programme was improving their child’s dental health. This interaction with the dental team has been shown by other researchers to reduce dental fear and improve knowledge about the biological basis of dental caries.11
Difficulties in Controlling Diet Most of the parents interviewed felt that controlling their child’s snacking on sugary foods was very difficult. Extended family members, especially grandparents, did not help the situation by offering ad lib sugary snacks. Children, it appears, are highly
Journal of Paediatrics and Child Health 50 (2014) 423–424 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
423
Dental decay
A Blinkhorn and F Blinkhorn
effective in outmanoeuvring their parents in order to obtain sugary snacks and drinks. In many of the families, sugar was equated with love and affection and control was seen as punishment, rather than being a healthy option.12
Overall Assessment of the Programme A major complaint was levelled at the dental health education leaflets by parents from non-English speaking backgrounds. Leaflets were too wordy and the illustrations were not helpful. All too often they thought advice was confusing, direct instructions were not given and jargon was used, which was not in their vocabulary.13 The problems with the leaflets relate to the theme of health literacy14 and highlight the need to pretest any advice leaflets very carefully. Many parents had not realised how vulnerable newly erupted teeth are to rapid decay. Yet the appropriate preventive behaviours are straightforward and apart from controlling in-between meal snacks, are relatively simple to implement. The American Academy of Paediatric Dentistry recommends children should visit a dentist for an oral health assessment by 12 months of age; however, this advice is seldom heeded.15 None of the parents had visited a dentist, but all of them had taken their child to see a family nurse or their local general medical practitioner. These professionals had not alerted them of the need to discontinue a night time bottle once the baby teeth began to erupt, nor advised brushing with fluoride toothpaste – two practical messages that could be delivered quickly and followed up with a minimum of ‘fuss’. These parents commented that they felt let down by the primary care services. The messages are simple: ‘Why did no one tell me?’ was a common response.
Conclusion Families who received the simple health education programme were desperate for their children to go to school with a healthy smile. Unfortunately, for many poor and disadvantaged children, this dream did not come true. More ‘joined-up’ health education advice is required from the primary care team in order to combat the problem of early childhood dental caries. The key to successfully reducing dental caries in young children will require community nurses and general medical practitioners to embed the ‘no bottle at night when the teeth come through, no sugary drinks in a feeding bottle and brush twice a day with fluoride toothpaste’ messages into their discussions with mothers who have young children.16 There is an online programme on Early Childhood Oral Health provided by The Royal Australian College of General Practitioners that gives succinct and practical advice on reducing dental caries in young children.17
424
References 1 Tickle M, Blinkhorn AS, Milson KM. The occurrence of dental pain and extractions over a 3-year period in a cohort of children aged 3–6 years. J. Public Health Dent. 2008; 46: 33–4. 2 Amin MS, Harrison RL, Weinstein PA. A qualitative look at parent’s experiences of their child’s dental general anaesthesia. Int. J. Paediatr. Dent. 2006; 16: 309–19. 3 Reisine S, Douglass JM. Psychosocial and behavioural issues in early childhood caries. Community Dent. Oral Epidemiol. 1998; 26: 32–4. 4 Arora A, Bedros D, Bhole S et al. Child family health nurses’ experiences of oral health of pre-school children: a qualitative approach. J. Public Health Dent. 2012; 72: 149–55. 5 Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children. A systematic review of the literature. Community Dent. Health 2004; 21: 71–85. 6 Department of Health. Weaning and the Weaning Diet, 45. London, UK: HMSO, 1994. 7 Tinanoff N, Palmer CA. Dietary determinants of dental caries, and dietary recommendations for preschool children. J. Public Health Dent. 2000; 60: 65–70. 8 Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst. Rev. 2003; 1: CD002278. 9 National Oral Health Promotion Clearing House. Oral health messages for the Australian public. Findings of a national consensus workshop. Aust. Dent. J. 2011; 56: 331–5. 10 Cashmore AW, Noller J, Ritchie J, Johnson B, Blinkhorn AS. Re-orientating a paediatric oral health service towards prevention: lessons from a qualitative study of dental professionals. Health Promot. J. Austr. 2011; 22: 17–21. 11 Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries: confirming the beneficial effects of counselling. J. Am. Dent. Assoc. 2006; 137: 789–93. 12 Roberts B, Duxbury JT, Blinkhorn AS. The ability of young children to influence adults in the choice of sugary foods and drinks. Health Educ. J. 2003; 62: 210–19. 13 Arora A, Scott J, Blinkhorn A. I can’t relate to teeth; a qualitative approach to evaluate oral health education materials for preschool children in NSW, Australia. Aust. Dent. J. 2012; 57: 57–8. 14 Nutbeam D. Building health literacy in Australia. Med. J. Aust. 2009; 191: 525–6. 15 The American Academy of Pediatric Dentistry. Recommendations for Pediatric Oral Health Assessments, Preventive Services, and Anticipatory Guidance/Counselling. 2013. Available from: http:// www.aapd.org [accessed 20 July 2013]. 16 Baric L, Blinkhorn AS. Embedded Health Promotion and Health Education. A Handbook for Health Professionals. Altrincham, Cheshire, UK: Barns Publications, 2006. 17 The Royal Australian College of General Practitioners (RACGP). (Centre for Oral Health Strategy, Early Childhood Oral Health: Case Studies from General Practice). 2013. Available from: http://www .gplearning.com.au [accessed 23 July 2013].
Journal of Paediatrics and Child Health 50 (2014) 423–424 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12469
VIEWPOINT
Preventing dental decay in young children requires all primary health care professionals to work together Anthony Blinkhorn1 and Fiona Blinkhorn2 1
Faculty of Dentistry, University of Sydney, Sydney and 2Faculty of Health, School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia
Untreated dental caries causes pain and suffering to children, as well as stress to the family.1 Young children with dental pain are difficult to treat and may require a general anaesthetic in hospital to receive dental care. This is expensive, carries a risk of death, can cause postoperative pain and treatment usually entails multiple dental extractions.2 Long wait lists for treatment of this type often means that young children can suffer pain and loss of sleep for over 12 months.3 Child and family nurses working in Western Sydney, New South Wales considered dental caries in young children to be one of the most significant issues in their daily working lives, especially in areas with large multicultural populations.4 Unlike many childhood health problems, dental caries is preventable with simple behavioural changes.5 The important health messages for families with pre-school children are: 1 Do not put a child to bed with a night time bottle once the baby teeth have begun to erupt.6 2 Do not allow a child to have sugar-containing drinks from a feeding bottle. 3 Restrict sugary foods and drinks to meal times, and drink fluoridated water.7 4 Brush the teeth gently twice a day with a smear of fluoride toothpaste.8,9 If these behaviours are implemented, then all young children should have healthy teeth. Unfortunately, in many socially disadvantaged areas of the city of Sydney, there is a tendency to: • Provide sweetened milk in night time bottles • Use sugar containing drinks as comforters for long periods of time during the day • Brush their child’s teeth infrequently10 As a result, their children may suffer an aggressive form of tooth decay termed early childhood caries, which destroys the primary dentition over a relatively short period of time. An education programme to help families improve the dental health of their young children is offered in the Paediatric Dental Department at Westmead Centre for Oral Health. The target group was those families with a child under 5 years of age waiting for dental treatment under general anaesthesia. Many
Correspondence: Professor Anthony Blinkhorn, Faculty of Dentistry, University of Sydney, 1 Mons Road, Westmead, NSW 2145, Australia. Fax: 61 2 88214370; email: [email protected] Conflict of interest: The authors declare no conflict of interest with this paper. Accepted for publication 24 October 2013.
of them were from non-English speaking backgrounds and had limited contact with dental care professionals. The programme emphasised the following key messages: 1 Parents/carer’s should supervise and help their children brush their teeth twice daily with a fluoride toothpaste. 2 Sugary drinks should only be given at meal times and never in a feeding bottle. 3 Children should not use a bottle at night as a comforter. In order to encourage the appropriate behaviour, free toothpaste, toothbrushes, diet advice leaflets and ‘sippy’ training cups were supplied. The programme proved very popular with dental staff as they were pleased to be focusing on preventive care, and the children enjoyed the experience and wanted to return for more visits. As part of the evaluation process, parents were asked to comment on the programme through a semi-structured interview. Three main themes were identified from the collected data: • Value of the setting • Difficulties in controlling diet • Overall assessment of the programme
Value of the Setting The advice programme was given in the Paediatric Dental Department at Westmead Centre for Oral Health. There were complaints about car parking, crowded waiting areas, having to travel to receive advice and taking time off work. However, the parents were prepared to ignore these difficulties as they held the dental team in high regard, valued the assessments and their children enjoyed the visits so anxiety was reduced and they thought the practical tooth brushing lessons were very helpful. Tooth brushing with fluoride toothpaste became a routine for all the family, and parents reported a reduction in their child’s dental pain. Having the teeth checked was particularly popular, as parents wanted the mouth monitored, as they felt unsure about whether the preventive programme was improving their child’s dental health. This interaction with the dental team has been shown by other researchers to reduce dental fear and improve knowledge about the biological basis of dental caries.11
Difficulties in Controlling Diet Most of the parents interviewed felt that controlling their child’s snacking on sugary foods was very difficult. Extended family members, especially grandparents, did not help the situation by offering ad lib sugary snacks. Children, it appears, are highly
Journal of Paediatrics and Child Health 50 (2014) 423–424 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
423
Dental decay
A Blinkhorn and F Blinkhorn
effective in outmanoeuvring their parents in order to obtain sugary snacks and drinks. In many of the families, sugar was equated with love and affection and control was seen as punishment, rather than being a healthy option.12
Overall Assessment of the Programme A major complaint was levelled at the dental health education leaflets by parents from non-English speaking backgrounds. Leaflets were too wordy and the illustrations were not helpful. All too often they thought advice was confusing, direct instructions were not given and jargon was used, which was not in their vocabulary.13 The problems with the leaflets relate to the theme of health literacy14 and highlight the need to pretest any advice leaflets very carefully. Many parents had not realised how vulnerable newly erupted teeth are to rapid decay. Yet the appropriate preventive behaviours are straightforward and apart from controlling in-between meal snacks, are relatively simple to implement. The American Academy of Paediatric Dentistry recommends children should visit a dentist for an oral health assessment by 12 months of age; however, this advice is seldom heeded.15 None of the parents had visited a dentist, but all of them had taken their child to see a family nurse or their local general medical practitioner. These professionals had not alerted them of the need to discontinue a night time bottle once the baby teeth began to erupt, nor advised brushing with fluoride toothpaste – two practical messages that could be delivered quickly and followed up with a minimum of ‘fuss’. These parents commented that they felt let down by the primary care services. The messages are simple: ‘Why did no one tell me?’ was a common response.
Conclusion Families who received the simple health education programme were desperate for their children to go to school with a healthy smile. Unfortunately, for many poor and disadvantaged children, this dream did not come true. More ‘joined-up’ health education advice is required from the primary care team in order to combat the problem of early childhood dental caries. The key to successfully reducing dental caries in young children will require community nurses and general medical practitioners to embed the ‘no bottle at night when the teeth come through, no sugary drinks in a feeding bottle and brush twice a day with fluoride toothpaste’ messages into their discussions with mothers who have young children.16 There is an online programme on Early Childhood Oral Health provided by The Royal Australian College of General Practitioners that gives succinct and practical advice on reducing dental caries in young children.17
424
References 1 Tickle M, Blinkhorn AS, Milson KM. The occurrence of dental pain and extractions over a 3-year period in a cohort of children aged 3–6 years. J. Public Health Dent. 2008; 46: 33–4. 2 Amin MS, Harrison RL, Weinstein PA. A qualitative look at parent’s experiences of their child’s dental general anaesthesia. Int. J. Paediatr. Dent. 2006; 16: 309–19. 3 Reisine S, Douglass JM. Psychosocial and behavioural issues in early childhood caries. Community Dent. Oral Epidemiol. 1998; 26: 32–4. 4 Arora A, Bedros D, Bhole S et al. Child family health nurses’ experiences of oral health of pre-school children: a qualitative approach. J. Public Health Dent. 2012; 72: 149–55. 5 Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children. A systematic review of the literature. Community Dent. Health 2004; 21: 71–85. 6 Department of Health. Weaning and the Weaning Diet, 45. London, UK: HMSO, 1994. 7 Tinanoff N, Palmer CA. Dietary determinants of dental caries, and dietary recommendations for preschool children. J. Public Health Dent. 2000; 60: 65–70. 8 Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst. Rev. 2003; 1: CD002278. 9 National Oral Health Promotion Clearing House. Oral health messages for the Australian public. Findings of a national consensus workshop. Aust. Dent. J. 2011; 56: 331–5. 10 Cashmore AW, Noller J, Ritchie J, Johnson B, Blinkhorn AS. Re-orientating a paediatric oral health service towards prevention: lessons from a qualitative study of dental professionals. Health Promot. J. Austr. 2011; 22: 17–21. 11 Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries: confirming the beneficial effects of counselling. J. Am. Dent. Assoc. 2006; 137: 789–93. 12 Roberts B, Duxbury JT, Blinkhorn AS. The ability of young children to influence adults in the choice of sugary foods and drinks. Health Educ. J. 2003; 62: 210–19. 13 Arora A, Scott J, Blinkhorn A. I can’t relate to teeth; a qualitative approach to evaluate oral health education materials for preschool children in NSW, Australia. Aust. Dent. J. 2012; 57: 57–8. 14 Nutbeam D. Building health literacy in Australia. Med. J. Aust. 2009; 191: 525–6. 15 The American Academy of Pediatric Dentistry. Recommendations for Pediatric Oral Health Assessments, Preventive Services, and Anticipatory Guidance/Counselling. 2013. Available from: http:// www.aapd.org [accessed 20 July 2013]. 16 Baric L, Blinkhorn AS. Embedded Health Promotion and Health Education. A Handbook for Health Professionals. Altrincham, Cheshire, UK: Barns Publications, 2006. 17 The Royal Australian College of General Practitioners (RACGP). (Centre for Oral Health Strategy, Early Childhood Oral Health: Case Studies from General Practice). 2013. Available from: http://www .gplearning.com.au [accessed 23 July 2013].
Journal of Paediatrics and Child Health 50 (2014) 423–424 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
