A Tooth Smart Prevention Clinic has been developed for the Paediatric Dentistry Department at Westmead Centre for Oral Health to provide:

• a prevention program for children who are on a general anaesthetic (GA) waiting list for dental treatment
• oral hygiene and dietary information and resources for parents/carers
• follow-up, including a dental check-up for siblings under 5 years of age.

The project commenced in February 2007 and evaluation results have shown positive changes in oral health knowledge and behaviour:

• 84% of parents/carers are now assisting their children with tooth brushing
• 68% are now brushing at least once a day
• 42% are drinking more water
• 73% have increased healthy snacks
• five have ceased bottle feeding.

To reduce the incidence of repeat dental treatment under a GA for high risk children and improve the oral health of the family, as a whole.

Early childhood caries (ECC) is a serious dental condition occurring during the preschool years of a child’s life when developing primary teeth are especially vulnerable. It can be a devastating condition often requiring treatment under a GA (Horowitz 1998; Milnes 1996). The pain, psychological trauma, health risks and the cost associated with restoration of these carious teeth can be substantial (Reisine & Douglass 1998). Factors that may increase the risk of ECC include: prolonged use of bottles of sugary drinks, especially at night; frequent sugar snacking; unavailability of fluoride; and bacteria transmitted on spoons, bottles and dummies (Ripa 1988).

In 2006-2007, 1720 children aged between 0-4 years of age received dental treatment under a GA in NSW. Family circumstances, such as low socio-economic background, increase the risk of ECC. Thus, to be more effective and efficient, a holistic family oriented approach is necessary (NSW Department of Health 2008).

The Paediatric Dentistry Department at Westmead Centre for Oral health is one of the major tertiary referral dental hospitals in NSW. The majority of referrals received are due to ECC.

At present, there are roughly 500 children (mostly under 5 years of age) on the waiting list for dental treatment under a GA. Some patients have to wait up to 12 months for treatment and during this waiting period carious teeth may deteriorate. Prior to this project parents/carers of these children have not been provided with a comprehensive information and prevention program to attenuate this condition.

The Tooth Smart Prevention Clinic aims to reduce the incidence of ECC in children under 5 years of age, in line with:

1. NSW State Plan (F4) (NSW Government 2006, p. 76-7)
2. State Health Plan (SD 1 make prevention everybody’s business - increase the proportion of 5 year old children without dental decay (Caries free) from 70% in 2000 to 77% in 2010) (NSW Department of Health 2007, p. 15)
3. Healthy mouths healthy lives: Australia’s National Oral Health Plan 2004 – 2013 (Action Area 4) (National Advisory Committee on Oral Health 2004, p. 27-9).

The Centre for Oral Health Strategy (COHS) NSW offers opportunities for Area Health Services (AHSs) to develop, or progress, an oral health promotion project annually. Sydney West Area Health Service applied for, and was successful in securing a grant to improve the oral health of 'high risk' children (0-4 years) on a GA waiting list, and their families. The program offers:

1. a prevention program for the child
2. an Oral Health Family Pack
3. a dental check-up to siblings under 5 years
4. 4-monthly follow-up visits.

A multidisciplinary management committee was established to oversee the project (Oral Health Promotion Project Officer, Dietician, Child and Family Health Nurse, Specialist Paediatric Dentists). A Tooth Smart Tips brochure was developed for parents/carers (focus groups of parents were held to test the brochure and ensure it was easily understood by the target group). Motivational resources for children were also developed, such as, a Tooth Smart magnet, sticker, colouring sheet and tooth brushing chart. In addition, a risk assessment tool and a dietary flip chart were developed for use by the Tooth Smart Team (dental therapists, dental assistants [and dietician - on request]) at the chairside.

The Tooth Smart Teams spend approximately 20 minutes with each family and speak about the causes of ECC and how it can be prevented. The families are provided with a take away Oral Health Family Pack (toothbrush, toothpaste, floss and disclosing tablets; information on the procedure for dental treatment under a GA; and relevant early childhood brochures that are available in a variety of languages) and a fluoride application is provided to individual children, as required, at the request of the specialist paediatric dentist.

The Tooth Smart Prevention Clinic has seen 150 families to date and 25 families have been recalled four months after the initial visit.

Nineteen (19) families (76%) attended the 1st recall visit in May 2008. They were provided with:

1. a further Oral Health Family Pack (toothbrushes, paste and floss);
2. oral hygiene and dietary support
3. a check-up for siblings under 5 years of age.

An evaluation was conducted on the families who were recalled to determine if any changes in behaviour had occurred in the four months from the initial visit to the recall visit. The following data revealed that participants reported positive changes in:

1. oral health behaviour (100%) and knowledge (89%)
2. assisting their children with tooth brushing (84%)
3. brushing their children’s teeth at least once a day with fluoride toothpaste (63% - an increase of 34% from initial visit)
4. drinking more water (42%)
5. eating healthy snacks (73%)
6. ceasing bottle feeding their babies and introducing a cup (5).

In addition, nine siblings under 5 years received a dental check-up, and 94% of participants stated they will return for the next recall appointment.

Further evaluation of this project is continuing with participants as they attend the recall visits.

The Tooth Smart Prevention Clinic will be rolled out to AHSs that provide dental treatment under a GA to children. AHSs can take advantage of a number of initiatives that are available to reduce waiting lists for GA and/or improve the oral health of children under 5 years of age:

• COHS has provided special funding to AHSs to reduce waiting lists for GAs.
• the Global Child Dental Health Taskforce (a WHO initiative) has provided NSW with 24,500 packages of toothbrushes and toothpaste, over a three year period, for children under 5 years.

The lessons learnt illustrate the following statements:

• Early childhood is the time when most lifetime habits are established. It offers the greatest opportunity for prevention of disease, which can contribute to better health in adulthood.
• ECC is one of the few chronic diseases that, if preventive messages are implemented, can be mostly prevented.
• Dental caries is a multifactorial disease and in early childhood is linked strongly to family behaviours and practices. Oral health services need to prioritise all eligible family members where one child is at high risk (NSW Department of Health 2008).

• Horowitz, HS 1998, Research issues in early childhood caries, Community Dentistry & Oral Epidemiology, vol. 26 (1 Suppl), pp. 67-81.
• Milnes, AR 1996, Description and epidemiology of nursing caries, Journal of Public Health Dentistry, vol. 56, no. 1, pp. 38-50.
• National Advisory Committee on Oral Health 2004, Healthy mouths healthy lives: Australia’s National Oral Health Plan 2004-2013, Australia’s Health Ministers’ Conference.
• NSW Department of Health 2007, A new direction for NSW: State health plan towards 2010, NSW Department of Health.
• NSW Department of Health 2008, Early Childhood Oral Health (ECOH) Program: The role of public oral health services, NSW Department of Health, Policy Directive, PD2008_020.
• NSW Government 2006, A new direction for NSW: NSW Government State Plan, NSW Government.
• NSW Health 2007, My First Health Record, NSW Health.
• Reisine, S & Douglass, JM 1998, ‘Psychosocial and behavioural issues in early childhood caries’, Community Dentistry & Oral Epidemiology, vol. 26 (1 Suppl.), pp. 32-44.

Associate Director - Clinical Governance, Clinical Governance Unit
Sydney West Area Health Service
Phone: 02 9881 7524