Background
Methods
Recruitment
Data collection
Data analysis
Results
Parents’ and children’s intentions of caring for teeth
Claire, the mother of a 6-year-old girl with a CL/P, used terms such teeth falling out or having black teeth to describe tooth decay. These expressions were commonly adopted by other parents and children. For instance, eight-year-old Ben understood that tooth brushing ‘cleans [teeth] and if you don’t clean then your teeth will rot’. Children talked about the association between not brushing teeth and caries and they were, therefore, motivated to brush their teeth because they did not want their teeth to ‘rot away’ (Oscar) or get ‘wobbly’ (Robin).I’ve always emphasised on it, because it’s always been, right, well, if you don’t want to brush your teeth then, A, they’re going to fall out, B, they’re going to go black and they’re going to fall out, or you’re not going to be able to chew your food. I always emphasise the consequences of not brushing your teeth. (Claire, mother).
Some parents also cited social acceptability as their motivation to encourage their children to brush teeth. For instance, Rachel, the mother of a 10-year-old boy with a CL/P, told their children to ‘go and brush your teeth! Because you don’t want to have smelly breath!’ In addition, parents expressed concerns about future CL/P treatments as contributing to a strong intention to look after their children’s teeth. The following mother, Alice, said she brushed the teeth for her child, explaining:Because when you smile, 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. (Jessica, 9 years old)
Lucy, the mother of a 7-year-old girl with a CL/P, was motivated to look after all of her children’s teeth, but distinguished her child with a CL/P because of her ‘problems’:We’ve just talked more about how he’s going to need braces and things, so that’s another reason for keeping on top of it. I think it’s been more motivating for us than for the others (who do not have CL/P). (Alice, mother)
All parents interviewed expressed strong and consistent intentions to look after their children’s teeth. Some children also reported firm intentions to carry out tooth brushing routine, but others were less engaged. Children’s intentions were more closely associated with social acceptability and none of them referred to the impact of oral health can have on future CL/P treatments. By contrast, parents tended to identify tooth decay and future CL/P treatments as their main motivation to care for their children’s teeth.Well, I want them to have nice teeth, that’s the most important thing for me, you know, and have a healthy mouth more than anything, her more than my son, of course, because of her problems but yes… (Lucy, mother)
Parents taking the lead
Some parents talked about the tooth brushing routine involving themselves or other family members. This was said to also encourage the tooth brushing behaviour of the child with a CL/P. In the following example, Claire described the morning tooth brushing routine in their household:Yeah, routine is just the key of getting up, having his breakfast, getting dressed, washing, brushing his teeth, going to school. So he knows it’s all in his routine. Sometimes he’ll say to me, it’s time to brush my teeth, you know, because it’s that scheduled. (Anne, mother)
The following father talked about the child with a CL/P brushing with his sister so they encourage each other’s brushing behaviour or ‘egg each other on’.We brush at the same time. It’s part of our routine. We’ll get dressed, we’ll do her hair, I’ll get my clothes on, we’ll go to the bathroom together, we’ll brush together and then we’re off then. (Claire, mother)
Ten-year-old Oscar’s parents in the following example described a monitoring role, asking Oscar if he had brushed his teeth and listening for the sound of the electric toothbrush.It’s kind of like egging each other along type of thing. She does exactly the same thing [as him]. She didn’t today, but she’s done it before where she’ll go off and do her teeth and she’ll go [Max, the child with a CL/P] you’ve not done your teeth. Then she’ll bring his toothbrush and his egg timer […] if he walks off she’s followed him. [She would say] I'm making sure that you're doing it properly. Then she'll come up to me and go, with a full brush of toothpaste, he's not brushing his teeth. (Martin, father)
Some parents in this study expressed challenges in balancing doing the right thing and preserving harmony in the family as some children were described as being disinterested or reluctant to brush teeth. The challenges parents faced are illustrated by Anne, who sometimes struggled to motivate her child, Robin, to brush his teeth:With him, he's not a very good liar. He would try and try and try so we'd stand there and go, think about it. Did you brush your teeth? Because I'll open your mouth and check it. Then he'll go, let me just go and check. Then he'll go and do it. (Hannah, mother)At the moment he's using one of those vibrating toothbrushes as well, so if you don't hear it, we usually check the sink as well. So if there is a large deposit of - so usually if he's done it quite well it's just very watery or frothy and stuff like that. If he hasn't then he's essentially just spat out toothpaste and stuff. (Martin, father)
Anne thought it was a natural reaction that her child was reluctant to brush because ‘he’s a child’. As the main enabler, parents found it challenging to balance tooth brushing, their children’s temperament and the various demands of family life.We do have traumas like them running round the table and they’re jumping over settees and, urgh, it’s not time to brush my teeth yet. (Anne, mother)
Obstacles to children’s tooth brushing behaviour
The following mother of a 9-year-old girl with a CL/P described taking responsibility for brushing her child’s teeth for the previous six months because her child found it difficult to brush awkwardly growing teeth.Interviewer: Right, so can you remember what was the reason that stopped you doing your teeth [after the bone graft surgery]? Only tell me, because I’ve never had one.Georgina: ‘Cause it hurt.Interviewer: It hurt did it? Yeah. And did it actually hurt even to put a toothbrush in your mouth?Georgina: It even hurt when I opened it.
Some children, like Noel, have a sensitive mouth that might be related to CL/P and brushing can cause pain and this can also lead to resistance in tooth brushing.I started brushing them myself, it’s been about six months I think, because she wasn’t quite doing it properly herself and she found it difficult to get in all…you know, like especially when all these teeth start showing at different angles, she found it difficult to brush herself.(Rani, mother)
Some parents reported that tooth brushing behaviour can be interrupted when children felt ill. Both long-term and short-term illnesses were presented as factors beyond parents’ control and described as inevitable obstacles to caring for teeth.[He just says his mouth’s sore, his teeth hurt […] he struggles expressing and telling me how he feels or he gets everything muddled up a bit and stuff, so he does struggle telling you, he just says he doesn’t like it and it hurts (Helen, mother).
‘Forgetting’ was also referred to by children and parents as an obstacle, either to brushing teeth or reminding their child to brush. When participants were asked why they forgot or why they found it difficult to remember, they referred to time constraints in the mornings and children’s tiredness in the evenings. The term ‘forgetting’ was sometimes used to describe conscious decisions to miss tooth brushing as well as failures of memory. This could be in response to managing routine challenges such as being late for school, or a child’s fatigue. For example, 9-year-old Jessica’s account below illustrates ‘forgetting’ to brush her teeth when she was in a rush in the morning:Well, she had a bug, so she was being sick all the time, and if she wasn’t sleeping she was burning up. She couldn’t move off the couch. This went on for about a week. So the last thing she wanted to do was go to the bathroom and brush her teeth. (Kirsty, mother)
Given the option of brushing teeth or being late for school, resulting in missing the register and subsequently losing the ‘green cushion’, brushing was described as something that could be traded-off and missed for the day. Some parents responded to questions about forgetting in a confessional tone, with a morally laden response as seen in Rani ‘s comment about allowing her child to miss brushing: ‘I’m not going to lie’:[…] when I’m late for school I’d miss the register or I don’t want to miss assembly, because sometimes we have this thing called green cushion, and it’s when you get, like, a cushion for being good that you can sit on, and then, like, if you get it you don’t want to be late to anything. (Jessica, 9 years old)
This may reflect the concerns parents had for doing their best to look after their children and presented themselves as only occasionally allowing their children to miss tooth brushing.Once or twice I have [allowed my child to miss brushing]. I’m not going to lie and say no, I haven’t. I have once or twice, I’ve said okay, but I still tell her but just give it a good rinse if you don’t want to do that two minutes. (Rani, mother)