Análisis a la observación de la clase a OD1T

Dental guidelines recommend that toothbrushing should be conducted or closely supervised by an adult until a child is around seven-years old (BDHF, 2010; NHS, 2009). The literature indicates that there may be some cultural variations in age of eruption of first primary dentition which may mean there are some cultural variations in when the routine might first be established.

Infants in Iceland are some of the youngest at 6.89 months (sd 2.16), infants in Nigeria 8.39 months (sd 2.93), Iraq 8.40 months (sd 2.20) and in Saudi Arabia 8.49 months (sd 2.81) (Folayan et al., 2007). Additionally, as has already been discussed earlier in the chapter there is no real firm evidence-base to support the age of seven- years as being the age at which adult supervision can stop, so there may also be some variation between different countries with regards to what age is considered appropriate for autonomous self-toothbrushing (Dos Santos et al., 2011). However, there does appear to be consensus that adult supervision during toothbrushing is important in the early years of life.

One potential reason why caregiver supervision may be necessary is that toothbrushes may pose a danger to young children if they are allowed to hold them unsupervised. There have been documented cases of toothbrushes causing serious oral trauma through becoming embedded in the tissues of the oral cavity (Belfer et al., 1995; Matsusue et al., 2011). Often these incidents happen because children are

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allowed to walk around with the toothbrush in their mouth, but then fall over, causing serious impalement injuries (Younessi and Alcaino, 2007).

A further reason why it is not recommended that children engage in self- toothbrushing until the age of seven-years is that infants may not have the appropriate fine motor skills necessary to manipulate the toothbrush to ensure their teeth are brushed to an adequate level of hygiene prior to this age. If toothbrushing is broken down into a ‘task-analysis’ it becomes clear that as an activity, it is actually quite complex. Task analyses break down daily-living and other tasks into the constituent micro-behaviours in order to allow children and adults with ASD to learn these tasks.

A toothbrushing task-analysis developed by the Dr Samuel D Harris National Museum for Dentistry, USA, for the ‘Healthy Smiles for Autism’ campaign (Dr Samuel D Harris National Museum of Dentistry, 2010), demonstrates the series of micro- behaviours involved in toothbrushing. These include picking up the toothbrush, picking up the toothpaste, taking the cap off the toothpaste and squeezing a pea- sized amount of toothpaste onto the brush. This initial series of micro-behaviours is required even before the act of actually cleaning the teeth with the brush begins. The task-analysis goes on to describe how the toothbrush is then used to brush the front teeth using a circular motion, brushing the inside surfaces of the teeth, brushing the top surfaces of the teeth, brushing the tongue, and then spitting out the toothpaste. The task-analysis then finally describes the processes of rinsing the

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brush, replacing the cap on the toothpaste, and placing the toothpaste and toothbrush back into their cup.

The task-analysis outlined demonstrates that toothbrushing is actually a complex task comprised of a series of micro-behaviours, some of which require relatively complex manipulation of the toothbrush in order to cover all tooth-surfaces adequately. This may explain in part, the fact that the dental expert guidelines recommend that children younger than seven-years should either have their teeth brushed for them by an adult, or be very closely supervised in order to ensure all teeth surfaces are cleaned adequately.

It is also recommended in the guidelines that caregivers should brush their infant’s teeth at least once a day, preferably twice, (AAP, 2007; NHS, 2009) and that this be done for a period of at least 2 minutes (NHS, 2009). In particular, caregiver-

conducted toothbrushing before bedtime is important as children may have food

debris in the mouth by the evening due to the chewing and ingestion of food throughout the day. Reduced saliva flow during the night also increases acidity of the oral cavity, increasing the likelihood of the process of dental caries (Hodosy and Celec, 2005). It is therefore important that food debris be adequately removed before bedtime in order to avoid the development of dental caries. Indeed, intervention studies have demonstrated that absence of nocturnal toothbrushing may be significantly associated with development of carious lesions in infants (Siqueira et al., 2010).

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Based on the literature, it could therefore be argued that during infancy, caregiver conducted dyadic toothbrushing in which the caregiver holds and uses the toothbrush to clean their infant’s teeth is important for preventing oral trauma from toothbrush impalement injuries and also ensuring good dental health. However, the behavioural difficulties common in infants and young children may potentially make it quite difficult for caregivers to maintain full control of the toothbrush as their child develops through infancy. Indeed, the literature would suggest that this may potentially be the case.

Firstly, a recent telephone survey of 1000 parents by the British Dental Health Foundation (BDHF) found that up to a fifth of under-fives may be brushing their teeth themselves, completely unsupervised (BDHF, 2008). This finding appears to support the idea that children are engaging in significant self-toothbrushing, and perhaps more than the dental guidelines recommend. In addition, a quarter of parents surveyed did not realise that twice-daily toothbrushing was needed in order to maintain their child’s dental health.

Findings from a qualitative interview study conducted with 48 Mexican-American mothers of young children (Hoeft et al., 2009) appear to confirm the findings from the BDHF (2008) survey. Mothers in this study did not establish toothbrushing routines with their children until they were on average 1.8 years old (sd .8 years), whereas American Dental Association (ADA) guidelines state that toothbrushing should be established at the time of the eruption of the first primary tooth. When

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mothers in this study were asked who conducted their child’s toothbrushing, many reported that their child did, despite their child being under the age of seven-years, which is the age at which it is recommended that children should be allowed to brush their own teeth (BDHF, 2010; NHS, 2009). A total of 87% of mothers from this study were found to be engaging in toothbrushing with their child that did not comply with ADA recommendations (ADA, 2002).

Additionally, a further qualitative interview study (Huebner and Riedy, 2010) conducted with 45 caregivers (44 mothers and 1 father) of children aged approximately 3 – 5 years living in a rural county of the United States, provides further support for the these findings. When the authors asked participants to describe a typical toothbrushing episode, only 11/40 (28%) of parents reported that they brushed their child’s teeth for them. This is in contrast to the 22/40 (55%) of parents who reported that they were simply physically present in the bathroom when their child brushed their own teeth, with the parent providing minimal supervision. An additional 7/40 (18%) of parents reported that their child brushed their own teeth completely unsupervised. The findings from these two qualitative interview studies (Hoeft et al., 2009; Huebner and Riedy, 2010) are discussed in more detail in Chapter Three of the thesis.

More robust data to support the findings from the BDHF (2008) survey data and the Hoeft et al. (2009) and Huebner & Riedy (2010) interview studies, are provided by two studies in which dyadic toothbrushing routines with infants were directly

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observed (Martins et al., 2011; Zeedyk et al., 2005). Although the studies were conducted with different samples of dyads, Martins et al. with 201 Brazilian dyads with mean infant age 3.4 years and Zeedyk et al. (2005) with 18 Scottish dyads, with mean infant age 2.5 years, both studies generated similar findings. Martin et al. found that around 34% of dyads engaged in toothbrushing in which the parent did not brush the infant’s teeth for them, with Zeedyk et al. (2005) finding this figure to be 33%.

Each of the studies previously discussed and summarised in Table 2.2 demonstrate that young children may be engaging in self-toothbrushing at a younger age than the seven-years that dental expert guidelines recommend (AAPD, 2011a; BDHF, 2010; NHS, 2009). Additionally, these two observational studies reveal that caregiver reports of dyadic toothbrushing may not be reliable when compared with observed toothbrushing practices. The two observational studies (Martins et al., 2011; Zeedyk et al., 2005) are discussed in more detail in Chapter Five of the thesis. Throughout the thesis empirical chapters, both qualitative interview and observational methodologies are used to explore and describe how infants begin to engage in self- toothbrushing, in addition to exploring and describing other caregiver-infant influences on dyadic toothbrushing.

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Authors Year Sample

Size

Population Methodology Main Findings

British Dental Health Foundation

2008 1000 British parents of children

(child age not specified)

Survey study 20% of children under the age of 5-

years are brushing without adult supervision.

Hoeft et al. 2009 48 Mexican-American dyads

(child age 5.8 years)

Interview study Mean age at which toothbrushing routines started in infancy was 1.8 years, with 87% of dyads parent not brushing child’s teeth for them by mean age of 5.8 years.

Huebner & Reidy 2010 45 American dyads (child age

3 – 5 years)

Interview study Toothbrushing routines started by age of 1-year in 78% of dyads and in 73% parent had minimal/no control over child’s toothbrushing.

Zeedyk et al. 2005 18 Scottish dyads (infant

mean age 2.5 years)

Observational study

33% of dyads parent not brushing infant’s teeth for them by age of 2.5 years.

Martins et al. 2011 201 Brazilian dyads (infant

mean age 3.4 years)

Observational study

34% of dyads parent not brushing infant’s teeth for them.

Table 2.2- Summary of published studies reporting child self-toothbrushing as occurring at a younger age than general health (e.g. NHS, 2009) and dental health (e.g. BDHF, 2010a) guidelines recommend

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If findings from these studies (BDHF, 2008; Hoeft et al., 2009; Huebner and Riedy, 2010; Martins et al., 2011; Zeedyk et al., 2005) are reliable, many infants and young children may be engaging in self-toothbrushing at a younger age than the seven- years recommended by dental professionals (AAPD, 2011a; NHS, 2009). Although there is no firm evidence-base to support the recommendation that children should not engage in self-toothbrushing until the age of seven-years, and also a lack of agreement internationally as to when self-toothbrushing should commence (Dos Santos et al., 2011), seven-years appears to be the age recommended in the UK (BDHF, 2010; NHS, 2009).

The complexity of toothbrushing, both as a tool use and self-care task, might mean that before the age of seven-years, children do not have the ability to hold a toothbrush using the kind of ‘oblique’ or ‘distal oblique’ grasps that develop in later childhood and are associated with better plaque removal. Indeed, observational research has shown that these more sophisticated tool grasps are associated with better plaque removal than the more simplistic grasps seen in earlier childhood.

In a recent observational study of children aged 10 years (sd 1.29 years) residing in India (Sharma et al., 2012) 100 school children attending a dental clinic were video recorded in order to analyse the kind of grasp they used to brush their teeth. On a

first visit, the researchers took a baseline plaque sample (PS1) using the Sillness-Loe

plaque index (Silness and Loe, 1964) and then instructed each child to brush their teeth using their usual method. Following brushing a second plaque sample was

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collected (PS2). All children were then provided with instruction of an optimal

toothbrushing technique, which included using an oblique grasp, brushing each tooth surface with a circular motion for a total of 3-mins. They were then asked to use this optimal method of brushing for seven-days.

All children returned to the dental clinic and each child was asked to demonstrate toothbrushing a second time, with this again being video recorded. Finally, a third

plaque sample (PS3) was collected immediately after the second toothbrushing

observation. Sharma et al. (2012) found that when although all children had been provided with toothbrushing instruction, 92% of them did not modify the grasp they used upon second toothbrushing observation. In terms of grasps used by the children at baseline, the most common grasp used was a distal oblique (67%) with an oblique grasp being used by just over a quarter (25%), and one child used a spoon grasp, whist another used a precision grasp.

When Sharma et al. (2012) analysed the plaque samples, they found that at baseline

(PS1) and then immediately after brushing (PS2), children using the distal oblique

grasp had significantly lower mean plaque scores than children using the oblique grasp (both p= .003). However, following toothbrushing during the second visit to the dental clinic (PS3), no differences were found between children using the distal oblique and oblique grasps, in terms of plaque score. Additionally, regardless of grasp type used, significant reduction in plaque scores were found between baseline

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clinic (PS2) and the second visit (PS3) (all p < .0001). This would indicate that although

both grasps result in plaque reduction, immediately after brushing, for longer term, sustained plaque reduction, the distal oblique technique is more effective.

Although the findings from Sharma et al. (2012) are interesting, there are number of limitations to the study. Firstly, in any kind of observational research, when an observational coding schedule is used, it is good practice to check the reliability of the coding schedule between different observers. Sharma et al. do not report any such inter-coder reliability assessment so it is unclear how reliable the coding schedule used to categorise each child’s grasp type was. Additionally, as children were filmed brushing their teeth in the dental clinic with a member of study staff present, the study may lack ecological validity and caused children to brush their teeth differently to how they would at home. It may have been preferable for caregivers to film their child in the natural home environment, in order to capture each child’s most natural toothbrush grasping technique.

Despite the limitations however, Sharma et al. have provided some preliminary data that suggests that grasp type does indeed affect the level of plaque on children’s teeth, and that therefore, how a child grasps the toothbrush may potentially affect their dental health. This may mean that if children are engaging in self-toothbrushing at an age when they are only able to use very simple grasp techniques, the effectiveness of toothbrushing in preventing caries may be compromised. Therefore, it may be important to examine the natural emergence of dyadic toothbrushing as a

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routine behaviour and uncover the influences which may be contributing to children engaging in autonomous self-toothbrushing at a much younger age than is recommended.