Three overarching themes were developed: (1) An engaging and personalised dental visit for parents and children; (2) Dental teams, parents and children working collaboratively to improve oral health habits, (3) Recommending appropriate oral health products.
Theme 1: An engaging and personalised dental visit for parents and children
For parents and children, there appeared to be little recollection of what was discussed within the dental visit:
At the time they told me what fluoride content to look out for but I can’t remember now. (parent)
Different approaches (outlined below) from parents, dental teams and children, were suggested. Preference was shown for dental visits to be friendly, fun and engaging, but still providing key support and education. As such, the current theme identified ways in which providing an engaging dental visit may encourage recollection and how having an attractive environment, including posters and the use of technology (e.g., TV and digital screens) could make going to the dentist less intimidating and more welcoming.
Visual displays and resources engage parents and children.
Many dental team members found that visual resources, such as posters within the clinic, helped draw the attention of both children and their parents. Utilising the dental waiting room for displays about oral health was seen as an efficient way to communicate oral health messages and stimulate conversations with the wider dental team, such as receptionists:
“So at the moment we are doing the sugar display, we did the dummies, the juice in bottles on display. The sugar display... nearly every patient makes a comment about it. It’s really, really good and obviously hear any patients discuss it with their children, so if we hear any patients doing that we like to get involved. So I sort of listen and if you hear them talking you will sort of say and explain why we’ve done it.” (Receptionist)
These findings reinforce how oral health can be delivered by the wider dental team, optimising every contact they have with the patient from the onset of the visit, including receptionists within the waiting area, making the delivery of oral health messages more memorable. Within these dental practices, there appeared to be a whole team approach, which was not dependent on one staff member delivering oral health advice. An active engagement as shown by this receptionist was a positive way of delivering oral health messages to families of young children which enabled them to think about their oral health before they went into the clinic and spoke in more depth with the dentist.
Wanting a friendly and interesting environment
Dental team members, parents and children alike, described how attractive resources and technology are more likely to capture their attention. A relaxing and friendly environment could help with the enhanced delivery of oral health messages:
“like it could be... the walls could be more colourful and they could explain it more nicely because when I go to the dentist, they always shout at me [...] like they just say in a strict way like ‘you have [stresses the word] to...’. I want it to be more like nice, like more giggly. (Year 4 participant)”
There was a desire for fun elements to be incorporated into their dental visit by using colourful displays, activities and rewarding their engagement with stickers, while also being informative. Having an environment that was appropriate to all audiences (i.e., child and adult) also appeared to be important. This is because some resources, such as leaflets, did not appeal to younger children; however, parents were more likely to engage with these and take them home. Interestingly, the child within the narrative above describes how the dentist appears to “tell off” the child and directly impose oral health messages. This, in turn, could make the dental visit appear intimidating for children and make it less likely that they will implement the advice given.
Involving the child within the dental visit
All participants identified the importance of involving children (aged 7-10 years old) in the visit. Dental visits provide opportunities for dental team members to talk to the child, as well as the parent, to help make them aware of the negative consequences of poor oral health:
“Rather than speak to the parent, speak to them because obviously some kids, especially at school, when you’re talking to them direct, they listen more so one to one sessions are better […]” (Nurse)
Children above the age of seven transition from being dependent on parents brushing their teeth, to exerting their own control and taking more responsibility for their oral health habits (11). This, in turn, allows parents to take a more supervisory and motivational role in their child’s toothbrushing. The focus groups highlighted how the child could be actively involved when the advice is communicated:
"If they notice a build-up of plaque anywhere then they will say you know you should be focussed on these areas. I would say my older boy has had x-rays and things recently and the dentist really had a good talk to us with that and like look at the x-ray and got him really quite involved with it which was really nice for him." (Parent)
“They also said, ‘Do you use mouthwash?’. I said yes and they said, ‘Do you use after you brush your teeth’, I said ‘yes’ and they said to me, ‘Don’t really do it. If you brush your teeth in the morning, then come back from school and do it, not after you’ve brushed your teeth” (Year 3 participant)
For children, how the message was conveyed was an important motivator, with oral health behaviours seen as advice entrusted to them rather than being imposed on them. This is important as dental team members can be perceived as telling patients what to do rather than exploring opportunities with patients, and thus these conversations were less likely to lead to behaviour change. The dental team members within the narrative of the current study had the opportunity to grasp the interest of the child by involving them within the oral health discussions. Having practical demonstrations (e.g., using disclosing tablets) alongside oral advice may have helped strengthen this engagement and recollection. Children within the focus groups showed an interest in being involved in these conversations and enjoyed viewing their x-rays and disclosed plaque. The dental team member in these instances had the potential to show why oral health behaviours were important, motivating children to place increased effort into maintaining good oral health.
Theme 2:Dental teams, parents and children working collaboratively to improve oral health habits
Children were aware of the importance of good oral health and wanted the responsibility to look after their teeth. The narratives highlight the issues children and parents face undertaking oral health behaviours and the critical role parents play in maintaining good oral health habits.
Reminders for the child to brush
Parents within the focus groups saw morning toothbrushing as a part of their school routine. The evening brush, however, was often left to the child and therefore more vulnerable to being forgotten:
‘’P: They said I have to brush in the morning and at night
I: Which one were you forgetting?
P: The night
I: Did they give you anything to remember to brush at night?
P: They said, ‘Your mum’s going to remind you at night’.’’ (Year 4 participant)
Getting ready in the mornings were reported to be "hectic"; however, they appeared to be more organised because parents took control to ensure toothbrushing was done within the routine of getting ready for school. Evenings, however, were less time-pressured and structured, with children often responsible for getting themselves ready for bed. The narrative highlights the challenges of achieving regular bedtime brushing and how important it is for dental teams to explore these routines as they may help to identify opportunities to support good bedtime habits.
Supporting healthy eating and drinking habits
Although children felt responsible for controlling their eating and drinking habits, most spoke about how difficult it was for them to maintain a healthy diet, especially once unhealthy habits had been established:
‘’I: Do you actually follow all the diet advice?
P2: It’s a little hard
P3: Because it’s really hard to get out of it’’ (Year 5 participants)
Interestingly, the narrative suggests that children, similar to adults, struggle to make healthy food choices, despite knowing what these are. This has been supported by dental team members who similarly discussed children’s regular access to sugary foods and drinks:
“He was brushing his teeth but … with all this fizzy drinks, he was my first child so, I just let him loose!” (Parent)
Although there is a shift in dependency, ultimately, it is the parent that has a crucial role in their child's oral health behaviours. Dental team members felt as though parents might have overlooked their role in regulating what food items are available to their children. Often, frustration was shown over who maintained responsibly in controlling sugary foods and drinks. Parents felt pressured to give in to children's demands as refusal could lead to uncooperative behaviour from the child, as shown by the phrase “going to have a paddy”.
‘’but there are a lot of parents that take on what you say and some parents that say, ‘well I ate loads of sweets and it didn’t have any harm’.’’ (Practice manager)
The dental team members reported difficulty in supporting parents who hold such strongly ingrained beliefs and were therefore more hesitant to deliver oral health advice. This narrative demonstrates how some parents may appear to be
Communicating good oral health messages to wider family and friends
Parents reported that social factors, such as school and cultural factors at home, strongly influenced their child’s sugar intake and lack of toothbrushing. The current sub-theme demonstrated the importance of communicating good oral health messages to wider family members and friends.
Some parents, for example, felt their partners were not as supportive in maintaining good oral health for their children:
''Saying that, going to the dentist hasn't but now he's getting older he's getting lazy and it is a push to get him to do them. He will do them but, say if I'm at work and he's at home with his Dad, guaranteed he won't do his teeth'' (Parent)
While some parents felt their child was responsible for their oral health habits, others described how their partner or other family members did not share the same beliefs in the importance of maintaining good oral health habits. Changing these family norms was viewed as challenging, particularly when parents were perceived as unmotivated. Parents often struggled to relay oral health messages to other family members who cared for their child, especially when often only one parent attended the dental visits.
Parents highlighted a need for other care environments to be aware of, and enforce appropriate dietary behaviours, such as schools (e.g., not provide sweet snacks after lunch), specifically as the child grows older and spends more time away from the parent:
‘’...it does concern me at school because we restrict sugary snacks at home but school doesn’t and I have actually written to local council about this. They offer at lunch time like puddings and cakes as well as fruit as an alternative but we all know what the children are going to go for so it’s kind of a bit deflating that we restrict but he isn’t obviously restricted at school.’’ (Parent)
The narratives show the importance of consistent messaging for families and schools, who are integrally involved in children’s lives. It identifies the challenges of communicating with wider family members who may have significant responsibility for looking after children, but have not attended the dental visit.
Theme 3: Recommending Appropriate Oral Health Products
The focus group discussions illuminated how recommendations of the appropriate oral health products can improve oral health behaviours, including toothbrushing for the right amount of time, motivating the child to brush, and establishing a good routine.
A focus on the practicalities of products
Dental team members discussed which dental care products they advised parents to use (e.g., toothbrushes and toothpaste), and were mindful of what products to recommend based on their price and long-term durability. Despite the preferences for, and the many advantages of, using electric toothbrushes, the cost of electric toothbrushes was viewed as a concern by dental team members:
“I think for me cost is something that you have to factor into it because if you say to parents, ‘right you’ve got to buy an electric toothbrush and this toothpaste’, there’s no point as they don’t have that disposable income. So you’ve got to be realistic. So I always tell them about the food colouring and I always make sure they are not allergic to it first and say this is what we use here but if you want a cheaper alternative!” (Practice manager)
“Yeah, yeah I mean we got the Star Wars flashing Lightsaber one that kind of gives you a time limit of 2 minutes. It flashes for 2 minutes and makes noises for 2 minutes so yes that worked until it broke but it’s very expensive so we didn’t get it again but it did make him respond.” (Parent)
Alternative products were suggested to parents by dental team members to increase the likelihood that they would follow and implement the oral health advice provided. This helped reduce barriers, by using a range of product costings and offering different options, such as food colouring rather than disclosing solutions or replacing the head of the electric toothbrush to allow other children to use. Within the narrative above, the child was motivated by the power toothbrush, and the inbuilt timer allowed him to brush for the allocated time.
Interestingly, many children and parents within the focus groups owned an electric toothbrush, indicating that assumptions made by the dental team regarding cost did not coincide with reality. The narrative highlights that parents are willing to buy appealing products, such as electric brushes if they were motivated to do so and could see the benefits of their purchase.
The importance of the products being attractive
The narratives highlight that children were often responsible for choosing which toothbrush to buy, and displayed a preference for electric toothbrushes, initially for their aesthetics and later for their practicality. This availability of attractive toothbrushes could potentially increase children to undertake good oral health behaviours:
‘’I: Who chooses the toothbrush for you and what do you prefer?
P1: I choose my toothbrush. I normally choose the one that is electric [...] I would choose that one [pointing to a product displayed] because it is FROZEN’’ (Year 3 participant)
The characters often grabbed children’s attention and increased the chance that they would ask their parents to buy a specific toothbrush:
‘’If I was younger and I liked CARS and things, I would brush with that. It might make me like it more because it has CARS.’’ (Year 5 participant)
As children grow older, however, the novelty of these characters could fade, and popular children's characters may be less likely to influence their choice. This was shown by Year 5 children who focused on the ease of electronic toothbrushes rather than the characters displayed:
I: Why do you prefer the electric toothbrush?
P1: It’s easier
P2: Less energy needed
P3: It cleans your teeth better [...] and the round ones are better (Year 5 participants)
Children often favoured the electric toothbrush because they believed it was easier to use and more convenient compared to a manual toothbrush.
The difficulties of transitioning onto stronger tasting fluoride toothpaste with higher fluoride content
Although children usually chose their toothbrushes, the focus groups identified that parents decided which toothpaste to buy. National guidance recommends that children should transition to toothpaste containing between 1,350-1,500 parts per million (ppm) fluoride around six years old or earlier if the child is at high risk of tooth decay (11). Some parents, however, reported the difficulty in transitioning their children from flavoured infant toothpaste (of around 1,000ppm and usually sweet or mildly mint flavoured) to a child toothpaste (of up to 1,500 ppm fluoride) due to the strong mint flavour.
“ I think they once had a go with ours but they found it too strong so, I bought a child’s […] I’ve never read it to be honest.’’ (Parent)
Following on from the notion that parents and children struggle to remember the advice given within the dental visit, including the appropriate fluoride content for their child (theme one), the narrative above suggests that parents may therefore look for toothpastes that are targeted towards infants or children, which may not match the correct fluoride content for their age. This could, however, cause longer term problems because it is more difficult to migrate to higher strength toothpastes with stronger mint flavours which are more appropriate:
‘’I’m always an advocate for not using fruity flavoured toothpaste. Try and get them on mint because as soon as they’re too old for the fruit stuff, it’s a shock to the system and they stop brushing their teeth because they don’t like it.’’ (Dental Nurse)
Therefore, some dental team members recommended using a small amount of family toothpaste with the stronger fluoride content from the outset to desensitise children to the strong taste and prevent later transitioning difficulties.