Parents’ and children’s knowledge of oral health: a qualitative study

of children with cleft palate

Word Count 4747

Karen Davies, Research Associate, PhD, University of Manchester

Yin Ling Lin, Lecturer, PhD, University of Manchester

Peter Callery, Professor, PhD, University of Manchester

Corresponding author Karen Davies, University of Manchester, School of Nursing,

Midwifery and Social Work, Jean McFarlane Building, Oxford Road, Manchester M13

9PL Karen.davies-3@manchster.ac.uk Tel. 0161 306 7668

Abstract

Background: Children with cleft lip and/or palate (CLP) are prone to poorer oral health

outcomes than their peers, with serious implications for treatment. Little is known of

the knowledge and practice of children with CLP in caring for teeth and how these

contribute to oral health.

Aim: To investigate (i) parents’ and children’s knowledge of oral health (ii) how

knowledge is acquired (iii) how knowledge is implemented.

Design: A qualitative design was used to investigate knowledge, beliefs and practices

reported by parents and children, age 5-11 years with CLP. Data were collected from 22

parents and 16 children and analysed using thematic analysis.

Results: Four themes were derived: (i) implicit knowledge: children express simple

knowledge underpinned by basic rationales (ii) situated knowledge: children gain skills

as part of everyday childhood routines (iii) maintaining good practice in oral health:

parents take a lead role in motivating, monitoring and maintaining children’s tooth

brushing (iv) learning opportunities: pivotal moments provide opportunities for

children to extend their knowledge.

Conclusion: Developers of oral health education interventions should take account of

children’s implicit knowledge and the transmission of beliefs between generations that

influence tooth brushing behaviours. This could enhance interventions to support

parents and children’s practice.

Key words: Children’s oral health, knowledge and practice of toothbrushing, cleft lip

and/or palate

Introduction

Children’s oral health is an important factor in their long term health and wellbeing 1.

Tooth decay is preventable through regular tooth brushing, reduction in sugar intake

and accessing the protective benefits of fluoride, but remains a primary reason for

young children being admitted to hospital for surgery2. Concerns about childhood

gingivitis and periodontitis are also reported in the literature, although the

inconsistency in case definition affects the reported distribution of periodontal disease

in children3. The Department of Health in England has prioritised caring for teeth with

the intention of ‘enabling people to take control of their oral health’ (p.3)4. Children with

underlying difficulties affecting dentition arising from cleft lip and/or palate (CLP) have

additional pressures in maintaining oral health related to surgical repair of the mouth,

atypical dentition and extensive orthodontic treatments. Evidence suggests that

children with CLP have more problems with oral hygiene than their peers, as indicated

by plaque5,6, gingival inflammation and greater incidence of caries7,8,9. However, little

research has explored the reasons for this. An improved understanding of the issues

encountered by children and parents could enhance the effectiveness of oral health

education10. National standards and guidance for advising families about caring for

teeth exist in England11 but is not followed consistently by dental health practitioners12..

Improvement in parents’ knowledge is only associated with short term changes to

children’s plaque and no discernible effect on caries13. Oral health educators are

encouraged to concentrate on indicators of empowerment as well as disease outcomes14

highlighting the need to understand children’s and parents’ knowledge in order to

develop more effective approaches to oral health promotion.

Little is known about how parents and children with CLP learn about oral health

and apply this knowledge to their behaviour. The following paper describes a study

investigating what parents and children with CLP know about caring for teeth and how

knowledge is applied in routine family life. The study explored both tooth brushing and

sugar intake in relation to oral health, but the findings reported here consider tooth

brushing behaviour, as a discrete activity related to oral health in contrast to the more

complex issues surrounding sugar intake. The study focused on parents’ and children’s

knowledge of oral health rather than on current status of children’s oral health.

The aims of the study were:

i. To explore the knowledge of oral health of parents and children with CLP.

ii. To investigate how parents’ and children’s knowledge is acquired.

iii. To explore how knowledge is implemented in family life.

Materials and Methods

Study design

An exploratory study employed qualitative methods to investigate oral health

knowledge, beliefs and practices in children with repaired CLP, as reported by parents

and children. A purposive sample of children aged 5-11 years, with repaired CLP and

their parents, was recruited to participate in semi-structured interviews in a specialist

cleft centre in the UK. The purposive sampling ensured variation in children’s age,

gender and type of cleft. The recruitment process closed at the point of theoretical

saturation, when no new themes emerged from additional cases 15.

Parents’ interviews followed a topic guide with 14 open ended questions

concerning experiences of managing oral health and barriers and facilitators in keeping

teeth clean (Table 1). Children’s interviews consisted of informal activities, such as

guessing games relating to foods, and a narrative framework 16 to encourage children to

verbalise a more complete account of their behaviour in caring for their teeth (Table 2).

The topic guides were designed by an advisory group consisting of researchers, dental

practitioners and service users. Parents’ and children’s topic guides were piloted with 2

parents and 4 children and amended in response to their comments prior to the

fieldwork.

[Insert Table 1 here]

[Insert Table 2 here]

Data collection

Parents were recruited at a specialist cleft centre in the UK during routine clinic

appointments. Dental practitioners explained the study to families where children

fulfilled the criteria and invited them to participate. Those who agreed, either attended

an interview session at the clinic, or provided contact details to be followed up by the

researchers. The researchers took informed written consent from the parents and

assent from the children before the face to face interview began and verbal consent for

telephone interviews.

Two qualitative researchers conducted the semi-structured interviews with

children and parents together at the cleft clinic (15 families) or parents’ home (5

families). The remaining 2 interviews were completed by telephone, without children

present. Providing the option of telephone interviews enabled the inclusion of voices of

participants who would have otherwise been excluded. Although the equivalence

between each mode of interviewing is uncertain17,18 these interviews were not dealing

with sensitive issues that required careful analysis of non-verbal cues. Data collection

took place over five months in 2015. Each interview with parents lasted 15-20 minutes

and children’s interviews took 10-15 minutes to complete. All interviews were audio

recorded and transcribed verbatim. The data were managed using the software package

NVIVO19. The interview process and data analysis were informed and monitored by an

advisory group that included dental practitioners, cleft specialists, parents and

researchers.

Data analysis

Data analysis followed the procedures of thematic analysis20. Interview transcripts were

systematically coded by two researchers using constant comparison of the data to refine

the codes21. The analysis involved an initial data management stage comprising of

creating codes for each case and recording these in NVIVO. A coding framework was

developed incrementally as transcripts were coded, with new codes added according to

issues identified in each subsequent transcript. The researchers coded each transcript

independently, compared the codes and agreed definitions. The second stage involved

categorising codes into a hierarchy to develop themes and sub themes in order to

facilitate interpretation. The reliability of the themes was verified by discussion with a

wider research group, a patient representative with CLP and a specialist dental health

professional.

Participants are identified in the results using codenames as follows: Parent (P1-22), Child

(C1-15) and Interviewer (I).

Ethics

Ethical approval was gained through the NHS NRES Committee West Midlands Ethics

Service (14/WM/1153).

Results

Twenty-two parents agreed to be interviewed (response rate 51%). There was a spread

of ethnicity and educational qualification (Table 3). An equal number of boys and girls

were recruited, with the majority of children falling into the older age range (31% age

5-7.11 years and 69% age 8-11 years). The sample included all forms of CLP, with the

greatest proportion of children diagnosed with unilateral CLP (Table 4).

[Insert table 3 here]

[Insert table 4 here]

The results describe four main themes derived from the analysis of interviews:

(i) children’s implicit knowledge (ii) situated learning (iii) maintaining oral health (iv)

learning opportunities for children with CLP.

Children’s implicit knowledge

The majority of children knew they should clean their teeth twice a day and

provided brief descriptions of what they did, accompanied by gesture. Very few

explained the detail of how they cleaned their teeth or could narrate a sequence of their

tooth brushing behaviour. Throughout their account they indicated that tooth brushing

was familiar and routine, but their limited verbalisation suggested that this knowledge

is largely implicit.

I: What do you do when you brush your teeth?

C20: I brush my teeth when I brush my teeth (Boy, 5 yrs)

Children’s rationale for looking after teeth were expressed simply, referring to

social acceptability, such as ‘looking nice’ and ‘being able to speak properly’, or being

healthy, for example, avoiding ‘rotten teeth’. They did not refer to the implications of

poor oral health in detail, with brief references to dental decay or dental treatment.

Parents indicated that their knowledge was implicit, also, ‘you just know what to do. It’s

just there’ (P1, mother, girl 10 yrs).

If you smile horrible rotten teeth no one will like your smile, but if you smile with nice clean

white teeth people will like it (C1, girl 10 yrs)

Parents also used simple rationales to explain the importance of oral health.

They tended to link social acceptability and health together in their explanations. Some

referred to previous surgery and treatment as an important motivator for maintaining

oral health, as illustrated by one parent:

I know that because she's had the cleft that her teeth are going to be more prone to decay

and to problems. She has been through 10 years or nine years of surgery to make things

right, and I think she would probably, maybe not in the word that I use would know that

that's a long time to go through to let poor dental hygiene affect that.

Well you can say well what was the point in the last 10 years if you're not looking after her

teeth now? (P11, mother, girl 9 yrs)

Some parents distinguished between children knowing what to do and

understanding the importance of caring for their teeth. There is an implication that

tooth brushing behaviour changes as children’s knowledge develops from implicit to

more explicit understanding. Children and parents referred to turning points where

children gained a greater understanding and participated more independently in

maintaining their oral health, as illustrated in this quotation:

I think once he realised there was a reason for it, for his teeth and stuff and fillings and all of

that, then he was much more willing to do it. (P4, mother, boy 8 yrs)

Tooth brushing habits were established from early childhood in the context of the

family, requiring children’s compliance but not necessarily their understanding. Parents

regarded their children’s understanding as helpful in acquiring children’s compliance

and vice versa. For example, P7 talked about the difficulties of motivating her child to

brush his teeth explicitly referring to his limited understanding:

I1: Because I suppose it’s difficult because he doesn’t understand.

P7: Yes, he doesn’t understand why they are doing this every morning.

Situated learning

Parents described a process of ‘situated’ learning, with children gaining skills as

part of everyday routines in infancy. Parents often referred to their own acquisition of

knowledge in similar terms, as a natural part of growing up. They described learning as

an intergenerational process, with knowledge passing from ‘generation to generation’

(P19 father, boy 9 yrs). Parents’ reported that their own situated learning was

influenced by life events. For example, one parent quoted his own experience of tooth

decay increasing his determination to teach his children, whilst several others referred

to learning from the experience of caring for a child with CLP.

Well obviously I learnt from being a child from my parents. Obviously I've learnt a lot of

things from C20, from going and seeing the dentist. Obviously everything in his mouth, you

know. I’ve learnt from C20 as well. (P20, mother, boy 5yrs)

Enabling situated learning was often described as a shared activity between

both parents. However, they expressed differences in how strongly they prioritised oral

health and persisted in monitoring their children’s tooth brushing. Several parents, who

were separated from their partners, believed that adequate oversight of tooth brushing

was not guaranteed when their children stayed in another household, indicating that

approaches between family members may vary.

Situated learning was also evident in children’s accounts of gaining knowledge.

Their explanations of how they learnt tooth brushing tended to be brief, with little

elaboration of how they learnt, reinforcing the notion that learning was ‘situated’, with

skills assimilated through family activities.

I: Who taught you to clean your teeth?

C2: My dad.

I: Your dad? Can you remember what he did?

C2: No (Girl 9 yrs).

There was consistency in children’s dialogue about the importance of the

parents’ role in their knowledge acquisition, describing parents as ‘telling’, ‘showing’

and ‘reminding’ them how to look after teeth. Some children referred briefly to a range

of other information sources, which included school lessons, dentists and internet

research, but parents were the principal ‘tutors’.

Given the lead role that parents play in children’s knowledge acquisition, the

accuracy of parents’ own knowledge plays a critical part in children’s tooth brushing.

Occasionally parents expressed confusion and misunderstanding about managing

children’s oral health. For example, one parent believed that children did not need

toothpaste if they avoided sweets, another suggested that brushing for extra time could

compensate for missed tooth brushing at other times in the week. Whilst these

misconceptions may seem idiosyncratic and difficult to identify the source of the

confusion, it indicates that parents can be susceptible to misunderstanding information

about ideal practices.

Maintaining good practice in oral health

The evidence from this study suggests that many parents are highly motivated to

encourage their children with CLP to care for their teeth, whilst their children show less

interest. Parents frequently referred to adopting strategies and resources to motivate

children to maintain tooth brushing behaviour and encourage independence. Some

referred to rewards, such as star charts and prizes, while others mentioned sanctions,

such as removal of ‘screen time’ or stories for children who were not co-operative.

Parents’ choice of strategy to maintain oral health tended to be determined by a number

of factors, such as the child’s mood, parents’ time or skills. The underlying subtext from

both parents and children is that caring for your teeth is a routine activity where

children and parents’ priorities do not always align. Parents may be motivated to

encourage children’s participation, ‘brushing your teeth shouldn’t be a chore’ (P5,

mother, girl 7 yrs), whilst children remain largely disinterested as illustrated by one

child, ‘I just find it alright. I find it like school, not really annoying, but not amazing’ (C15,

boy 8 yrs).

In spite of this child’s limited enthusiasm, he was able to demonstrate intentions

to maintain oral health, including caring for his gums, describing developing his own

strategy that he believed prompted better tooth brushing in the absence of adult

direction.

Like 10 seconds on my teeth bit, then 5 seconds on my gum, and then all the way until I get to

there, then I just do it randomly. (C15, boy 8 yrs)

Some parents acknowledged that maintaining oral health was difficult for them

and expressed a need for extra support and education to address the difficulties they

encountered. On occasions, this was implied in the words of parents, although others

described a point that triggered their realisation that their knowledge and practice was

insufficient.

I don’t think we’ve really had a lot of support, ‘cause it wasn’t until the last time I was at the

dental hospital when I, sort of, realised that we need more help here. I can’t seem to get the

decay under control, you know, it’s, sort of, spiralling. (P21, mother, boy 10 yrs)

Learning opportunities for children with CLP

The special circumstances of caring for a child with CLP provided opportunities for

learning about oral health. Parents referred to opportunities for reinforcing or changing

habits in tooth brushing as children matured. These ‘pivotal moments’, such as

additional treatment for CLP or problems with dental decay, referred to optimal

moments to learn about or change oral health behaviours. Parents attributed these

learning opportunities to children’s deeper understanding of the importance of oral

health as a result of their CLP. In the following example, the bone graft operation was

considered a pivotal moment that prompted deeper understanding for the child:

I think it kind of really sank in just before his operation, the recent one he's just had before his

bone graft when we went to the hospital………. He understood [the need for tooth brushing] last

year from us telling him, but I think with other professionals telling him, doctors and nurses, I

think then it sank in a little bit more (P17, mother, boy 8 yrs)

Some children also referred to pivotal moments that prompted a change in

thinking and behaviour. This generally followed consultation with dental practitioners

or cleft specialists, signifying a transition in tooth brushing behaviour from ‘knowing

what to do’ to ‘understanding and doing with confidence’. This transitional phase

suggested there may be a gap between gaining tooth brushing skills (knowing what to

do) through situated learning in infancy and knowledge built on understanding the

rationale for maintaining oral health (understanding why it is important) gained as the

child matures.

I think she is more aware of why she needs to brush her teeth now, whereas before it was

just because mum told her to brush her teeth, but now she knows the importance of

brushing her teeth (P11 mother, female 9 yrs)

Parents made comparisons between the information provided to children with and

without CLP. Children with CLP and their parents experienced more access to training

sessions, repeated advice and additional resources, contrasting with their experience of

caring for children without CLP, where advice was perceived as limited.

They often go through it each time……..No one’s ever said with the other kids and said what we

should be doing (P4, mother, boy 8 yrs)

In summary, many parents described a shift in children’s understanding that

prompted a qualitative difference in their tooth brushing behaviour, such as cleaning for

longer or paying greater attention to how they cleaned their teeth. Whilst the presence

of CLP is often associated with difficulties in looking after children’s teeth, this data

suggests that children with CLP access learning opportunities and receive better advice

and guidance about looking after teeth. The presence of CLP can be seen to create

opportunities for practitioners and parents to enhance or change children’s oral health

behaviour.

Discussion

The majority of children in this study were able to describe basic knowledge of oral

health but it is difficult to discern how much they understood of the consequences of

maintaining oral hygiene, including understanding of periodontal disease, for future

treatment for CLP. The family, including, siblings and wider family, play an important

part in helping children acquire knowledge and learn appropriate brushing behaviour.

Three main issues arise from the study.

First, children’s knowledge is predominantly implicit, acquired through a process

of situated learning22 during infancy as part of routine care activities at home. Tooth

brushing habits are likely to be formed before children understand the importance of

oral health and becomes an activity that is based on implicit knowledge. This affords

both advantages and disadvantages. The advantage of routine activities occurring

automatically with little conscious thought provides some reassurance that the activity

will not be forgotten. Some families described routines that are ‘natural’, ‘automatic’

‘learnt right from the start’. Nevertheless, there may be disadvantages of implicit

knowledge for oral health. Children’s understanding is likely to be incomplete, as

illustrated by their limited descriptions and interest in oral health. The potential for

knowledge and behaviour to remain limited, in spite of children’s development in other

areas, may lead to risks of persistent poor habits. Evidence from previous studies

indicates that implicit knowledge can be difficult to express and, as a result, difficult to

modify 23, 24.

Second, parents play a lead role in facilitating ‘situated’ learning, transferring

their own knowledge about oral health to their children. They believe they transmit

knowledge and oral health behaviours to their children that have been largely acquired

in their own childhood. This is regarded as a powerful learning process associated with

establishing long term behaviours. However, its strength can potentially be problematic

when parents have limited knowledge about oral health 25 and perceive learning about

oral health as ‘common sense’ that needs little additional guidance 26. This could result

in the transmission of firm beliefs and established behaviours that are not consistent

with current scientific knowledge about optimal oral health care. The importance of

maintaining the health of gums as well as teeth, that has gained greater prominence in

recent years27, may be an example of how intergenerational knowledge may not keep

abreast of present-day evidence.

Third, shifts in understanding and behaviour arise from opportunities for

parents and children to learn, often related to significant events affecting their teeth.

These were associated with CLP treatment or dental decay, suggesting that there may

be ‘teachable moments’28 when individuals are more receptive to health messages. Oral

health routines and habits are believed to be easily disrupted and open to infleunces

related to changes in the environment29. Findings from this study suggested that

changes in children’s circumstances, such as going through additional dental treatment,

may also prompt learning and encourage positive changes in tooth brushing behaviour.

These teachable moments, therefore, can be potentially useful when trying to establish

or modify a routine in oral health behaviour. Occasions that prompted learning,

deepened understanding and generated changes in behaviour were recalled as pivotal

moments by both children and adults.

There are two clear implications for managing children’s oral health arising from

the study. First, early infancy could be an important time for practitioners to promote

positive oral health habits. Subsequently, contacts with dental health professionals

provide opportunities to consolidate children’s implicit knowledge when children may

be more receptive to deepening their understanding. Second, parents have a leading

role in determining children’s situated learning in infancy. Supporting parents to

acquire correct knowledge and enact their intentions to maintain oral health routinely,

in spite of changes in their child’s or family circumstances, is potentially important for

improvements in oral health.

Our study has limitations. First, there was an element of self-selection in the

sample, although the response rate of 53% is comparable with other interview studies

and the sample included social and ethnic diversity. However, it is possible that those

who were less motivated or encountered greater difficulties with oral care may have

been less willing to talk about their experience in a research interview. Our findings

about oral health learning are consistent with and contribute to understanding previous

reports about unaffected children, but our CLP sample limits the extent to which

findings can be applied more generally. Nevertheless, the findings about pivotal

moments may have wider application if dental practitioners can identify similar

moments in the lives of children without CLP and use these to improve their knowledge

of oral health.

Second, social desirability bias may have influenced the responses of

interviewees. The tendency to answer questions in a way that will be viewed favourably

may contribute to over-reporting of positive oral health behaviour and should be taken

into consideration in interpreting the findings.

Finally, parents and children were interviewed individually, but in the majority

of cases, parents were present during the children’s interviews. This may have

influenced the responses children gave, whether positively in encouraging children’s

reporting or negatively in inhibiting their responses.

In conclusion, children, whether with or without CLP, are likely to need ongoing

oral health education to transform implicit knowledge into explicit knowledge that

informs and enhances tooth brushing behaviour. Parents are critical to this process and

building their skills as facilitators, to enhance children’s understanding of maintaining

healthy teeth and gums, as well as tooth brushing behaviour, should form part of the

continuous process of oral health education.

Why this paper is important to paediatric dentists.

Paediatric dentists take a lead role in providing advice and guidance to children and their

parents. Findings from this study suggest that children’s knowledge of oral health may be limited by learning that

occurs in infancy and remains implicit. Providing the opportunity for children to articulate their knowledge and

gain understanding of the consequence of maintaining oral health should be emphasised in oral health

education.

Oral health education depends on parents as facilitators of children’s learning as well as

behaviour. Supporting parents to be the medium of a continuous process of oral health education depends on

paediatric dentists building parents’ skills in implementing knowledge in their own unique family context.

Acknowledgments

The authors are very grateful to parents and children who participated

enthusiastically in the study and to the cleft palate specialists who enabled the

recruitment of families to the study. This project was funded by the National Institute

for Health Research for Patient Benefit (ID: PB-PG-0613-31022). The views and

opinions expressed therein are those of the authors and do not necessarily reflect those

of the, NIHR, NHS or the Department of Health.

Contributors

Peter Callery designed the research, analysed the data, and drafted and revised the

paper. He is the guarantor. Karen Davies and Yin Ling Lin collected and analysed the data, and

drafted and revised the paper. Jeanette Mooney facilitated recruitment and provided expert

advice relating to data collection and interpretation. Saff Bahm provided expert advice relating

to interpretation of findings from as a service user. All members of the ACORN Advisory and

Management Group advised on development of the study: Chris Armitage, Haydn Bellardie,

Vicky Brand, Nancy Bray, Victoria Clark, Susana Dominquez-Gonzalez, Lars Enocson, Kat

Kandiah, Deborah Moore, Kevin O’Brien, Bill Shaw, Martin Tickle, Stephanie Tierney, Tanya

Walsh, Cath Wright.

Funding: This project was funded by the National Institute for Health Research for

Patient Benefit (ID: PB-PG-0613-31022).

Competing interests: None

Ethical approval: Approval gained from NHS NRES Committee West Midlands –

Solihull; reference 14/WM/1153

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Supplementary

Table 1 Topic guide for parent interviews

Section 1: Dental care routines

Tooth brushing

1. What do you do to look after your children’s dental health? What kind of things do you

do differently for your child with CP if at all?

2. Can you describe your child’s tooth brushing routine

a. Who usually brushes their teeth?

b. When, how often, how long, type of brushes, type of toothpaste,

c. Is it automatic or prompted: how do you remind your child?

d. When (at what age) do you think your child understood that cleaning their

teeth was important?

e. How does it link with other daily routines?

f. Parents’ role-how do you check how well they are doing?

3. How did your child learn about tooth brushing? What has been most useful in

encouraging your child’s tooth brushing? Why?

Drinks and snacks

4. Can you describe your child’s usual drinks and snacks? When does he/she have them?

5. How much difference do you think this makes to the care of his teeth-what would your

child say?

6. Who chooses the drinks and snacks?

Dental treatment

7. What difference does it make when your child goes to the dentist?

8. What does your child think about going to the dentist?

9. How often do they go/ Who do they see?

Section 2: Barriers and facilitators

10. How would you sum up your role in supporting your child’s dental care? Who takes

charge of looking after your child’s teeth

11. Do you or your child sometimes forget about looking after his teeth?

12. What support has you and your child had to help them with dental care? Is there

anything you would have changed?

13. What is the most important in helping your child look after his/her teeth?

Section 3: Views about future study

We are going to compare different approaches to helping children with CP look after their teeth.

We will put people who agree to take part into 3 different groups, allocating them by chance to

receive one of three different approaches to looking after their teeth. We will then compare how

they each one works by asking the dental nurse to check the child’s teeth after 3 months.

14. Would you be happy to participate in any one of the groups? Reasons?

15. What information would parents want before they agree to allow their child to take

part

16. How would you like the information about the study presented-verbal, written or

other means?

17. How would be the best way to ask parents to be involved-email/post/face to face?

Any other comments and thanks

Table 2: Topic guide for children’s interview

Section 1: Looking after you teeth

Let’s start with a picture-this is me; you can draw yourself, then using a story framework

What do you usually do to look after your teeth? [who, how often, when, where]

So tell me exactly what you do when you clean your teeth?

What helps you look after your teeth? What helps you the most?

How do you remember to brush your teeth? [routines/other activities]

What kind of things get in the way of you looking after your teeth?

How do you feel about brushing your teeth?

Section 2:Beliefs and understanding

Let’s look at this boy-he might need your help [picture of boy cleaning his teeth]

How would you help this boy look after his teeth?

What kind of problems do you think he has with his teeth? [Why?]

Why do you think that would help him?

Can you think of anything that would help him?

Let’s tell him what to do using speech bubbles

What should he do?

What makes it easy or difficult?

How would you help him?

What do think helps you the most?

Can you make up a way to help him remind himself to look after his teeth

Visiting dentist – purpose, own experiences

Section 3: Snacks and drinks – habits and routines

What are you favourite treats and snacks and drinks?

How often do you have them?

How do you get your snacks and drinks?

Section 4: Snacks and drinks – knowledge and understanding

These boys and girls are going away to stay with his gran and he’s deciding what snacks and drinks to take

What treats do you think he should take? Why?

Will it make any difference to his teeth? In what way?

Are there good times to eat these treats?

Could you make up a motto to help him remember how to look after his teeth when he’s away?

Thanks

Is there anything else that you want to tell me about looking after your teeth before we finish?

Have you got any other questions about the study I am doing?

Thank the child for their help.

Table 3: Parent characteristics

Ethnicity NumberWhite 17Asian/Asian British 5Highest level of qualification of parentPublic examinations at age 16 (General Certificate of Secondary Education, GCSE)

8

Public examination at age 18 (Advanced Levels, A-levels) 9Degree 2Postgraduate 2

Table 4: Type of CLP in children of parents recruited to study

Type of cleft palate RecruitedCleft lip 3Cleft palate 4Unilateral CLP 10Bilateral CLP 5Total 22