The study findings are reported with reference – and response - to the research questions.
How public health nurses assess oral health in preschool children
Public health nurses in this study assessed oral health via three mechanisms: observation, parental attitude and communication. Observational assessments were primarily through direct noting of the condition of a child’s teeth. For most public health nurses in this study (n=10), this tended to be opportunistic, rather than a planned activity, for example:
I would just look at their teeth as I was chatting to the children. PHN 6
Just a smile… a smile of a child you can sometimes see things aren’t as they should be. PHN7
It’s the time during a home visit, you know, to go up to a child and say, ‘let me see your smile’ and doing it that way. PHN 15
For most participants (n=10), observation tended to be opportunistic, rather than a planned activity, for example when a child laughed or smiled. For many, direct observation was deemed to be beyond their sphere of practice:The majority of participants (n=11) reported that they also use parental dental health as a proxy indicator of the likely condition of a child’s teeth:
It’s not something I would do. PHN 8
I wouldn’t say it’s my role to look in a child’s mouth. PHN 9
No never, never because I wouldn’t know what I was looking for… PHN 12
[If mum] has got very decayed teeth herself I suppose that is another indication for me to be alarmed about what is going on with the children’s teeth by looking at the parents. PHN 3
I would always look at the parents’ dental health, because it is much more obvious at times. You know particularly looking to see what kind of state their teeth are in. That would be one of the first things that I would look at. PHN 4
Her own dental health and the care of her own teeth is going to reflect how she’s going to look after her child. Certainly my experience of the mother whose teeth are poor, are the ones I would look at in the child. PHN 6
Assessment of parental attitude was the second domain relating to how public health nurses assess children’s oral health. Feeding and weaning practises were cited by most participants (n=14) as key issues, particularly the use of bottles, dummies/pacifiers, juice and sweets/candies. Parents’ own experiences were also cited and six participants alluded to parental dental fear as an alerting risk factor for dental decay. Finally, regarding communication, most participants reported using discussion with parents on oral health issues to inform their assessments, such as asking about registration with a dentist (n=15) and while advising about teeth brushing (n=13):
Even if the child has no teeth I’ll say to her [mother] ‘still brush the gums and just get the child used to having the toothbrush in their mouth’. PHN5
Assessment of oral health issues was not confined to the family. A small number of participants (n=4) reported that they also discussed with other professionals and used information documented within family records to inform their assessments. Overall, findings pointed to a range of methods used by public health nurses in the study to inform their assessment of dental health. There were, however, some actual or potential barriers to assessment.
Barriers to assessment
Barriers to assessment were concentrated around issues of public health nurses’ role and parental expectations around that role. Just under half the participants (n=7) said that they were unlikely as public health nurses to look into a child’s mouth and, therefore, would not be aware of any dental problems with a child’s back teeth unless the parent raised a concern. Other barriers were cited explicitly around parameters of the public health nurse role, with five participants stating that their role in dental health was advisory, for example:
I think the role is much more of an advisory one and offering advice about brushing and the effects of diet and carbonated drinks on children’s teeth and offer suitable alternatives. PHN 11
As indicated in the following excerpts, a child’s oral health status tends to be part of the ‘bigger picture’ of factors present for children and at the time of assessment, may not be top of the public health nurse’s ‘agenda’:
You would just see them ad-hoc at clinic and it [oral health] may not be on the top of my agenda. PHN 4
It’s probably not the top most of your mind when you are going into these families. You know, the basics there, are they safe, are they eating, are they growing, are their needs being met? So it’s not always your thought, ‘Oh by the way can I have a look in your mouth?’ PHN 14
Issues around parental expectations highlighted some interesting perspectives. Seven participants explained that they did not look in children’s mouths routinely, because this was not expected by parents. Moreover, findings indicate that some believed that to do so, may be construed by parents as being intrusive:
I think it would depend very much on the parent and it would depend on the parent’s attitude to services and authority and some parents I think would find it quite intrusive. PHN 1
It’s quite an intimate thing to look inside someone’s mouth. PHN12
I suppose there maybe is a little bit of a feeling of that as well, that it’s maybe being a little bit intrusive or a little bit invasive. PHN 15
The issue was also raised regarding dental health as a sensitive issue. This called for careful balancing regarding the need to make appropriate assessments of a child’s health and the need to foster positive relationships with parents:
It’s trying to do it a bit more subtly, because you want to see them again. You don’t want them to say, ‘I’m not going to see her again’ PHN 7
It’s really difficult because health visiting is a service that’s offered to everyone but no-one has to let me in [to their house], no-one has to uptake that service, they can say no. PHN 12
Threshold levels of dental decay that indicate the need for targeted support
We found that, although levels of dental decay were not directly assessed by the public health nurses, they nevertheless considered it part of their decision-making regarding targeted support. The nurses used surrogate measures as proxies for dental health based on the two broad indicators of concerns about dental health and social issues. Ten participants cited social determinants such as homelessness, poor housing, domestic abuse and parental substance misuse as alerting issues:
We are looking at their development, parenting styles, emotional, social, play all that kind of thing and also physical well-being. So yes, it’s just part of the general assessment. PHN 5
The children with the more problematic dental health are the children where there’s other issues are going on… other issues of neglect or other issues for the mother, maybe the mother’s got mental health problems or other issues so environmental issues, social issues, other health issues. PHN 6
You’re looking at the risk factors… whether the parents are substance misusers, victims of domestic abuse, sexual abuse and just, their own family history. PHN 13
The public health nurses who took part in the study appeared to place emphasis on the broader, sociological influences on children’s health in assisting them in their assessments:Their interventions regarding targeted support consisted of two main strategies: provision of additional resources to promote dental health and referral to dental services.
The sort of things that would worry me particularly would be relationship issues, mental health, poor social circumstances in a damp house or overcrowding or a quick change of address. PHN 6
I think the obvious ones [concerns] are probably domestic violence, alcohol and drug misuse, probably single mothers who are unsupported… young mothers… PHN 7
Several times I would leave toothbrushes and toothpaste. PHN 3
I advised mum about the importance of going to the dentist and advised mum about the importance of getting her to brush her teeth and because we have access to dental packs I gave her one of the dental packs. PHN 16
Factors beyond which child protection intervention is initiated
Findings show that untreated dental caries or significant dental pain are threshold levels for child protection intervention. In such cases, referral to dental services and sharing information with relevant partner agencies were the primary interventions employed by the public health nurses who took part in the study. Although the majority (n=11) reported that in their experience dental decay was most often a marker of broader neglect, a similar number (n=12) expressed the opinion that dental decay alone would not necessarily raise a child protection concern. There were two key indicators for when a child protection intervention may need to be considered: a child suffering from untreated dental caries or significant dental pain (n=10) and parents failing to take their child for dental care after being advised (n=7):
Well obviously if the child was in pain, if the child had any pain and the parent wasn’t attending to that pain. That would be child protection concern. PHN 6
[Child protection intervention may be needed] if there are no… if the family are not registered with a dentist… if they’re not accessing a dentist or there is evidence of poor oral health. PHN 15
In this study, public health nurse interventions in response to child protection concerns consisted of two main strategies: referral to dental services and sharing information with relevant partner agencies. Almost half of the public health nurses interviewed (n=7) indicated that they would facilitate either further dental appointments or the child’s attendance at appointments. Interestingly, whilst they recognized the issue, the referral was to dental services, but they did not mention concurrent referral to child protection services. Eight public health nurses reported that they would include (or consider including) information regarding the child’s dental health within child protection reports or risk assessments shared with partner agencies:
[I state it] very clearly in every report… it would be very clear that you have provided them with the information for a dentist and to date they’ve still not registered or they have registered but not gone. PHN 9
I think if it was part of an overall picture of neglect and you knew it was a major issue then you would have to [include it] when you were doing the report. PHN11
Regarding communication, many participants reported that they are reliant on parental reporting of attendance at dental services and outcomes for children, rather than through formal liaison channels with other agencies, hence:
I’ve never had a phone call from a dentist to say this family have come and I’m appalled or you know, I’ve never had a phone call from a dentist. PHN 9
I’ve made quite a few referrals [to dental services] and I’m just thinking, you know, ‘What’s happened? Have they been seen or have they not? Have they attended?’ PHN 14