Background: Many high-caries-risk children in England receive dental extractions under General Anaesthesia (GA), this has become the leading cause for child hospital admissions in the country. King’s College Hospital (KCH) in South London is one of the largest GA service providers in England. Despite the radical approach to treatment under GA, many families re-attend the service for more treatment either for the same child or for a sibling, indicating failure to improve caries prevention. Parents of children referred to KCH for dental extractions under GA previously revealed to the author that they face challenges in preventing dental caries, one of which was having gaps in their oral health knowledge. They requested more support from the hospital, and suggested audio-visual media as an acceptable method for delivering oral health education to their families. Oral health education is a small, yet important, part of oral health promotion.
Aim: To develop and test an oral health education video-game, and assess the children’s compliance and views on fluoride varnish application within the pathway of care of children receiving dental extractions under GA at KCH. This will be achieved by: (i) exploring the challenges local General Dental Practitioners’ (GDPs) face in promoting oral health in those children; (ii) modifying a previous oral health education video-game to make it appropriate for use as part of the GA care pathway; (iii) assessing the game’s acceptability to the children and their parents, and its impact on the children’s oral health knowledge and practices in comparison to one-on-one verbal advice given by a Dental Nurse with Additional Skills (DNAS); finally, (iv) assessing the children’s compliance and their views about having Duraphat® fluoride varnish applied to their teeth in a medical clinic within the hospital’s GA pathway
Methods: A series of research steps was performed. First, a qualitative study that involved semi-structured interviews with a purposive sample of local GDPs who have referred children to KCH for dental extractions under GA was performed. Second, a prototype oral health education video-game, designed to fit with the primary-two Scottish curriculum, was modified using more recent technology to address the oral health education needs of children referred to KCH for dental extractions under GA, as informed by contemporary evidence for caries prevention, the findings of previous research involving their parents, and the views of the GDPs in this thesis. Finally, a blind Randomised Controlled Trial (RCT) recruited a sample of children attending at KCH for dental extractions under GA, and compared the new video-game to one-on-one verbal oral health education delivered by a DNAS in terms of: (i) child and parent acceptability using a 100 mm Visual Analogue Scale (VAS); (ii) effect on child’s dietary knowledge using a 70-item Pictorial Dietary Quiz (PDQ); (iii) effect on child’s snack selections and toothbrushing frequency as reported by child-completed diaries; (iv) effect on dietary practices as reported by a parent-completed Children’s Dietary Questionnaire (CDQ); and finally, (v) effect on attendance for follow-up after GA. Children from both groups also received an application of Duraphat® fluoride varnish and were asked to indicate what they thought of it using a VAS and a short structured interview. Outcome measures were collected at: baseline; immediately following the intervention; on the day of the GA; and three months after the GA.
Results: In the qualitative study, eighteen GDPs (56% male) were interviewed. They perceived challenges to the promotion of oral health in high-caries-risk children that were related to: (i) the child; (ii) parents; (iii) social and cultural environment; (iv) primary dental care training and remuneration; (v) hospital communication and engagement upon referral; and finally, (vi) national health promotion policies. In parallel, they perceived that the referral to the hospital for extractions under GA was a chance to capture and educate the families that they thought lacked knowledge on dental attendance and hidden sugars. The Scottish oral health education video-game was made available on a touch-tablet and modified by introducing new graphics and voice-over, and adding advice on: the cariogenicity of fruit juices and fruit drinks, brushing with 1450 ppm fluoride toothpaste, as well as the importance of regular application of fluoride varnish and regular dental attendance. In the RCT, 109 children were recruited. The majority (84%) came from deprived neighbourhoods. Their average age was 6.5 years [SD=1.6], and they were scheduled to have a mean of 6.7 primary teeth extracted under GA [SD=4.1]. The children had an unhealthy diet at baseline, including low consumption of fruits and vegetables [Mean=9.6; CDQ recommended: ≥14], and high consumption of sweetened drinks [Mean=2.4; CDQ recommended: ≤1], non-core foods [Mean=2.3; CDQ recommended: ≤2], and fat from dairy [Mean=4.0; CDQ recommended: 0]. The children and their parents found both methods of education highly acceptable [Video-game child median VAS=97; SD=25]; [Video-game parent median VAS=91; SD=20], [Verbal education child median VAS=99; SD=27]; [Verbal education parent median VAS=98; SD=10], although the parents seemed to slightly favour one-on-one education [Mann-Whitney-U test P=0.003]. Children from both groups were better at identifying unhealthy foods immediately following the education [Video-game PDQ score improvement=4.8; t-Test P<0.001; 95%CI=3.0-6.6] [Verbal education PDQ score improvement=7.6; t-Test P<0.001; 95%CI=5.1-10.1], with no differences between the groups [t-Test P=0.7]. However, those in the one-on-one education group were better at identifying fruit juice [Chi-Square P=0.014] and fruit drinks [Chi-square P=0.037] as unhealthy. Seventy six children (70%) returned completed snack diaries and toothbrushing diaries on the day of the GA. There were no significant differences between the groups in reported snack selection [Mann-Whitney-U test P=0.59] or toothbrushing frequency [Mann-Whitney-U test P=0.44]. Only 59 parents (55%) completed phone follow-up three months after the child’s GA, and reported small changes in dietary practices, including less sweetened drinks [CDQ score improvement=0.5; t-Test P=0.019; 95%CI=0.1-0.8], non-core foods [CDQ score improvement=0.3; t-Test P=0.046; 95%CI=0-0.6], and fat from dairy consumption [CDQ score improvement=0.6; t-Test P=0.037; 95%CI=0-1.3], with no differences between the groups. The improvements did not make the children’s scores reach the questionnaire’s thresholds for a healthy diet except in the non-core foods parameter. Non-respondents (45%) reported higher consumption of sweetened drinks at baseline [CDQ score difference=0.8; t-Test P=0.02; 95%CI=0-1.7]. Both education methods failed to achieve good attendance for a three month follow-up visit, as only 11 families in total (11%) attended. Only 39% of the parents were familiar with fluoride varnish at baseline. One hundred and five out of the 109 children taking part in the RCT were offered the treatment. Application was unsuccessful in only four children (4%). The children found the application acceptable [VAS mean=62; median=82; SD=40], and described the process as "easy". However, some said that they found the varnish “disgusting” or “sticky” and suggested different flavours.
Conclusion: The introduction of an educational oral health intervention, which also included applying fluoride varnish, within the hospital’s care pathway for children needing dental extractions under GA, was acceptable to the children and their parents. The oral health education delivered, whether verbally or using a video-game, improved the children’s dietary knowledge in the short-term, but long-term retention could not be confirmed due to poor follow-up attendance. Verbal education was found slightly more acceptable by the parents, and led to better recognition of some cariogenic items by the children. As such, it might be more suitable for this setting. Neither method of education delivery seems to have led to substantial dietary changes or better dental attendance in this cohort. The overall findings of this thesis highlight the challenges in providing support to high-caries-risk children referred for dental extractions under GA and their families; referring dentists felt that they could not provide the preventive care and oral health education that those children need in their primary dental practices and requested more efforts at the hospital, but delivering an oral health intervention at the hospital was not sufficient to achieve substantial changes in those children’s oral health practices. Future efforts are needed to address the barriers discussed by the GDPs in this thesis, and explore possible approaches and collaborations to provide more support with caries prevention to those children and their families.