Key points

  • Different communication behaviours were observed between dentists and extended duty dental nurses (EDDNs) when providing preventive dental care to children.

  • EDDNs seemed to apply a more empathetic and child-centred approach, whereas dentists used more direct communication strategies to gain children's treatment cooperation via the parent.

  • Preschool children are able to have oral health-related conversations with dental professionals, when space and time is made available.

  • A child-centred approach should be adopted in general dental practice through adjusting communication styles and tailoring oral health-related messages.

Introduction

Communicating with young children in the primary dental care (PDC) setting is particularly challenging for dental health professionals (DHPs). Reasons for these difficulties are said to include time pressures in general practice, child dental anxiety and associated behavioural management problems, and parental concerns.1,2,3 These difficulties are associated with young children's phase of their psychological development, their level of understanding and cognitions together with their language. Taken in conjunction, with child dental anxiety and the potential for regression, these developmental factors may intrude upon the child's capabilities to interact with the DHPs.

Consultations involving child patients are usually conducted with an accompanying parent and if the parent is overly anxious for the child's welfare or experiences dental anxiety themselves, this may increase the complexity of communication strategies required to care for both child and parent. Hence, to enable a treatment alliance to occur and for treatment to begin, DHPs will require special communication styles when engaging with young children and their parents. The communication styles adopted by the DHPs will permit a special form of interaction to develop known as the triadic interaction which gives rise to the treatment alliance.

There is little available evidence with regard to understanding the triadic interaction and what type of communication strategies are used by DHPs when interacting with children and their parents in the primary care setting.4 With an understanding of the communication strategies of different DHPs, it would be possible to strengthen the treatment alliance and assist DHPs to provide quality and effective preventive oral healthcare to maintain children's dental health. Nevertheless, the question remains what types of communication strategies do DHPs use in primary dental care? Therefore, there is a need to explore the types of communication used by DHPs when providing fluoride varnish and oral health advice to the child patient and their accompanying parent, using the reliable and valid video observational study protocol. The aim of the study was to explore the time taken and the types of communication strategies used by dental health professionals (DHPs) when interacting and providing fluoride varnish and oral health advice to children with their parents.

Method

Study design

A cross-sectional observational study of preventive care appointments in the primary dental care setting was conducted using video recordings.

Sample

Purposive sampling was used to identify participants who had the specific characteristics of a population of children and parents who attend for fluoride varnish application in primary dental care and the dental health professionals (dentists and extended duty dental nurses) who apply the fluoride varnish. Using this sampling approach, parents and their children and the dental health professionals who fulfilled the inclusion criteria were invited to participate.5

A purposive sample of five DHPs with various levels of clinical experience from four general dental practices in East of Scotland were invited to participate and took part in the study. The Scottish Index for Multiple Deprivation (SIMD) for the participating practices was assessed, the DHPs' clinical experience as the number of years in practice since qualification and gender were obtained. Fifty child-parent pairs were recruited from the four participating practices. The inclusion criteria for child patients were those who could speak English and aged 2-5 years with no developmental impairment. Of these, six observations were excluded for further video data analysis, due to: (a) two pairs of twins were treated with their twin siblings; (b) one child was the sibling of another participating child and was invited by the parent to receive fluoride varnish application (FVA) during the video observation; (c) one child was excluded due to learning difficulties.

Development of Paediatric Dental Triadic Interaction Coding Scheme (PaeD-TrICS)

A number of attempts have been reported to develop behavioural coding systems for child and dental health professionals.6,7,8 The Paediatric Dental Triadic Coding Scheme9 was developed to catalogue and define the triadic interaction between dental professionals, parents and children in terms of verbal and non-verbal behaviours in a clinical setting. The majority of the coding items were drawn from the St Andrews Behaviour Interaction Coding Scheme (SABICS), which was developed for EDDNs and child behaviours observed during the FVA in a nursery setting.6

This new coding scheme consisted of 45 verbal and non-verbal behaviours exhibited by one of the three participants: that is, DHP, parent or child (Table 1). Additional codes were assigned to new behaviours observed during the dental consultations in this study and included in the new coding scheme. These comprised of the DHPs' strategies used commonly in managing children's anxiety, such as 'TSD (tell-show-do) talk', 'reassurance', 'offer for alternative task' and those for encouraging child cooperative behaviours such as 'praise', 'reward (stickers)' and 'dentally engaging talk'. Children's communication behaviours included their verbal behaviours such as 'speech yes', 'speech no', 'speech other', 'dental talk', 'laugh' and 'cry'. The reliability of inter-examiner observation was assessed (inter-class correlation coefficient) and found to be acceptable.9

Table 1 Paediatric Dental Triadic Interaction Coding Scheme. Reproduced with permission from Yuan et. al., 20189

Data collection

Video recordings were collected when child patients with accompanying parents visited their general dental practices for preventive care appointments. The video recordings allowed direct observations of DHPs' communication strategies when interacting and providing preventive dental care (that is, oral health advice and fluoride varnish application) to child patients with their parents.

Children's demographic information, previous dental experiences and their appointment related information (for example, accompanying family members at the appointment) were collected. Children's age, gender and previous experience of FVA were obtained. These variables allowed the homogeneity of the patient group to be assessed.

Statistical analysis

Video recordings were uploaded onto Observer XT 10.5 and coded.10 Chi-square tests were applied to ensure the demographic characteristics and past FVA experiences of the children treated by different DHPs were similar. Communication strategies were assessed by identifying observable verbal and non-verbal behaviours. The verbal behaviours of both the DHPs and the children were calculated by time duration in seconds and frequency for each behaviour over the whole consultation per minute. DHPs' non-verbal behaviours were calculated as frequencies over consultation per minute. The coded behaviour data were then exported into SPSS v24 (SPSS Inc., Chicago, IL, USA) for detailed analysis. Descriptive statistics were calculated as mean frequencies of coded behaviours per minute and time duration of each dental preventive visit was used to compare the differences of communication strategies between dentists and EDDNs. Comparison tests were conducted using a nonparametric Mann-Whitney U-test. Two-sided tests were used throughout. Alpha was set to conventional 0.05.

Ethical considerations

Ethical approval was granted from the East of Scotland Research Ethics Service (Ref: 16/ES/0081). The present project adhered to guidelines of the Declaration of Helsinki and the participating dental health professionals and parents have provided their written informed consent to take part in this study prior to the preventive dental appointments.

Results

Demographic profiles of dental professionals and their practices

One practice was located with a SIMD score of '1' (most deprived), one scored '5' (least deprived) and remaining two scored '2' indicating the second most deprived area. The DHP sample was comprised of three dentists (one male) and two EDDNs (both female). The qualified clinical experience of the participating DHPs covered a wide spectrum, with one female dentist having over 10 years, another female dentist having 5 years' experience and the male dentist completing his vocational training. The two EDDNs had over 10 years of post-qualification experience.

Children's demographic and dental experience characteristics

Forty-four child-parent dyads participated in the study with 28 being treated by EDDNs. There was a statistically significantly greater proportion of girls in the dentist group compared with the EDDN group whereas larger proportions of single children were seen by the EDDN compared with the dentist group. There were no statistically significant differences in child age (months) or previous FV experience between the two DHP groups (Table 2).

Table 2 Comparison of demographic and dental care experiences of child patient groups treated by dentists and EDDNs

Communication strategies: duration and number

The preventive care appointment duration ranged from 130 seconds to 1,756 seconds with an average of 736 seconds. The total number of communication strategies (verbal and non-verbal behaviours) based on 44 video observations was 7,299. The average number of distinct verbal and non-verbal behaviours of codes assigned per appointment is 161. This was calculated from 29 communication behaviours of the child patient, 88 communication behaviours of the DHP and 42 communication behaviours of the parent.

Communication behaviours of dentists and EDDNs

In terms of consultation time, EDDNs spent longer (mean = 1,015 seconds) than dentists (mean = 350 seconds) with children and parents (Z = 5.34: p <0.001). Figure 1 shows that differences were found in the mean frequency of dental professionals' communication behaviours, adjusted for appointment duration time. EDDNs used more frequently the following verbal behaviours during FVA such as: using a 'pet name', providing a 'joke/humour', 'reward (eg, stickers)', 'distraction using toys', 'permission seeking' and non-verbal praise behaviours to engage the young child. Dentists more frequently used the verbal behaviour techniques of: 'instruction', 'praise', 'tell-show-do (TSD)' and 'relate experience' (that is, relating the current FVA to the child's previous FVA experience).

Fig. 1
figure 1

Comparison of communication behaviours between dentists and EDDNs (frequency per minute). *P <0.05, **P <0.01, ***P <0.001.

During oral health advice sessions, communication strategies such as 'information giving' and 'offering for question' to parents were used more frequently by EDDNs whereas the dentists more frequently used 'information seeking (questioning the parent)' to prompt the conversation with parents concerning their child's oral hygiene and diet. The communication behavioural code 'dentally engaging talk' (eg, 'how many times do you brush your teeth?') to engage the children, was used more frequently by EDDNs than dentists for both FVAs and oral health advice consultations (Table 3). In terms of non-verbal behaviours, EDDNs were more likely to use models to demonstrate to both child and parent toothbrushing techniques compared with their dentist colleagues (Table 3).

Table 3 Comparison of mean frequency of verbal and non-verbal communicative behaviours between dentists and EDDNs (frequency/min)

Children's responses to different DHPs' communicative strategies

Children treated by EDDNs compared with those treated by dentists had more communication behaviours such as: 'speech yes' (eg, agreeing to sitting in the dental chair), 'speech other' (eg, responding to comments about their teddy bear) and 'dental talk' (the child responding to dental health-related questions eg, regarding toothbrushing) (Table 4 and Figure 2). Children treated by dentists were more likely to say no to any procedure which was coded as 'speech no'.

Table 4 Comparison of the mean child responding behaviours between the patient groups of dentists and EDDNs (frequency/min)
Fig. 2
figure 2

Comparison of child responses between dentists and EDDNs treated groups (frequency per minute). *P <0.05, **P <0.01, ***P <0.001

Discussion

The aim of this exploratory study was to identify the time taken and the types of communication strategies used by DHPs when interacting and providing fluoride varnish application and oral health advice to children with their parents in the primary dental care setting.

Child-centred approaches are being discussed once more. The importance of including the child and the recognition of child participation in the healthcare setting11,12,13 is now seen as central to positive treatment outcomes. The inclusion of child participation in dental healthcare, is therefore needed if practitioners are to communicate appropriately and address children's needs for successful health outcomes.12,13 A number of communication strategies were observed during the preventive dental appointment between the DHPs who participated. The findings indicated that both dentists and EDDNs used a range of different communication styles during fluoride varnish application sessions and that these were used at different frequencies, even when adjusted for consultation time, between the professional groups. Dentists tended to use more direct communication strategies such as 'instruction' when interacting with parents to enhance the children's attention and compliance. It may be suggested, however, that the focus upon parental engagement at the expense of the child resulted in poorer child participation. This proposition is supported by the findings reported here as the children were less responsive to the dentist's communication strategies. EDDNs' observed communication strategies were different. They engaged first with the child and used 'child speech' to involve and provide an opportunity for the child to participate in the preventive care appointment. They exhibited this by 'permission seeking', 'telling jokes' and providing rewards to encourage involvement, the child's participation using oral health advice prior to FVA. This, we believe, supported and reinforced the child's coping behaviours during the preventive care appointment. These findings also indicate that dentists are more likely to use what might be summarised as an authoritarian style of communication. EDDNs on the other hand, were more likely to use a more 'symmetrical' communication style; that is working with the child at their level commensurate with their stage of psychological and cognitive development.

The work here represents an exploratory video recording study which used a purposive sample of children and DHPs working in a handful of general dental practices. Nevertheless, the in-depth assessment of communication strategies (verbal and non-verbal behaviours) of 44 video recordings and the identification of 7,299 codes allows a number of hypotheses to be raised regarding the use of different communication strategies between DHPs and their child patients. Therefore, future research is needed to explore the generalisability of the findings presented here. The effectiveness and the underlying mechanism of communication through various behavioural techniques can be inspected in detail and therefore enable evidence to be collated on how to encourage young children to receive dental care.

Previous work has indicated that children have a limited contribution to triadic communication in the healthcare setting.14,15,16 In our study we found that children's participation was measurable and almost exclusive to their interactions with EDDNs. Furthermore, our study indicates that younger children (under 6s) are able to have oral health-related conversations with dental professionals, when space and time is made available for them to do so. The children also appeared to understand the oral health-related information tailored by dental professionals when simple and appropriate language was used, as in the case of EDDNs. It may be postulated that these findings support the adoption of a child-centred approach by tailoring oral health-related messages for young and very young children.17

There are limitations of this study. Successful fluoride varnish applications between the two DHP groups were the same. This was an exploratory study18 and as such, it was not necessary to conduct a power calculation to reveal an FVA difference between staff groups, therefore we did not wish nor were we are unable to test which communication strategies were more effective in improving successful fluoride varnish application.

This exploratory study, nevertheless, demonstrated that differences in communication behaviours between dentists and EDDNs when providing preventive dental care to children were observed. The participating EDDNs seemed to provide a more empathetic and patient-centred treatment alliance with children, whereas dentists used more direct communication strategies to gain children's treatment cooperation, via the parent. Further research is needed to test the effectiveness and identify appropriate timing of using communication strategies to obtain young children's treatment cooperation.