Australian Dental Journal

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1 Australian Dental Journal The official journal of the Australian Dental Association Australian Dental Journal 2013; 58: doi: /adj Internet information on child oral health and the first dental visit CK Yeap,* LM Slack-Smith* *School of Dentistry, The University of Western Australia, Perth. ABSTRACT Background: This study evaluated the available online information regarding a child s first dental visit (CFDV) and compares this with internationally recognized guidelines for the timing of CFDV. Methods: Online information regarding CFDV was searched using the Google search engine under the Australian domain for four selected search terms and limited to the first 50 results. The websites of selected professional dental associations were also investigated for recommended CFDV timing. Guidelines recommended the CFDV from when the first tooth erupts or by the age of one year. Results: Information on timing for CFDV was available on the internet and consistent with recognized guidelines for almost half of the 157 sites examined. Information on CFDV was consistent with guidelines when mentioned in professional dental association and public (government and corporate) sites. Misinformation regarding CFDV was primarily associated with dental forums and sites owned by dental professionals. The three most popular topics of additional information included oral hygiene instruction, procedures for age-one CFDV and preparing the child for the CFDV. Conclusions: Internet information regarding a child s first dental visit was generally informative but not always in agreement with the recommendations of professional dental associations. Misinformation regarding CFDV was primarily associated with dental forums and dental professional owned sites. Keywords: First dental visit, oral health literacy, child health, oral health. Abbreviations and acronyms: CFDV = child s first dental visit. (Accepted for publication 24 October 2012.) INTRODUCTION Many authors suggest that the age of a child s first dental visit (CFDV) can be important in influencing paediatric oral health. 1 3 Current consensus among international paediatric dental guidelines recommends a CFDV from the time when the first tooth erupts (approximately six months old) to the age of one year. 3 6 A CFDV by the age of one year encourages the early establishment of dental care at home, which enables the early implementation of preventive and interceptive measures to address dental diseases and promote paediatric oral health. 1,2 Early familiarization with the dental environment can reduce a child s dental anxiety 4 and early dental education can assist the parents in managing the oral health of their children. 2,4,5 Early paediatric dental attendance could be positively influenced if parents knew of the benefits of having a CFDV by the age of one year. One possible source of information is the internet, which has become an increasingly important platform for obtaining healthcare related information. 7,8 As of September 2010, an estimated 60% of all adult Americans (aged 18 years old and above) had utilized the internet for seeking healthcare information. 9 A recent telephone survey reported that 12.6% of adult Australians regularly seek health information via the internet. 10 In the only identified similar paper, online information on the CFDV was readily available and accessible, but not necessarily reliable and authoritative. 6 The aims of this study were to investigate: (1) what online information regarding the child s first dental visit (CFDV) was provided by paediatric dental associations; (2) what advice about CFDV was available on the internet; and (3) whether the advice on the internet agreed with guidelines provided by professional dental associations. MATERIALS AND METHODS This study was a quantitative analysis of online information relating to the CFDV. By using selected search terms (Table 1), online information regarding the CFDV was searched via the Google search engine Australian Dental Association

2 Internet information on child oral health Table 1. Keywords used in online search for information regarding CFDV Baby first dental visit Child first dental visit Baby dental care Child dental care Table 2. Availability of and timing for child first dental visit recommended by selected professional dental associations Selected professional dental associations Availability of timing recommended for CFDV American Academy of Pediatric Yes [from first tooth Dentistry* erupts to 1-year-old] British Society of Paediatric Yes [1] Dentistry Australasian Academy of n/a Paediatric Dentistry Australian and New Zealand n/a Society for Paediatric Dentistry International Association of Yes [1] Paediatric Dentistry Australian Dental Association* Yes [1] American Dental Association* Yes [From first tooth erupts to 1-year-old] *Included in the final sample (157 sites). under the Australian domain (location predetermined at Perth, Australia; classic mode, URL: google.com.au/) from 5 pm on 23 July 2011 until am on 24 July The first 50 search results for each of the selected search terms were compiled and analysed for the type of site and the timing recommended for CFDV. Similarly, the websites of seven professional dental associations were searched for information regarding CFDV (Table 2). International paediatric guidelines suggest the first dental visit should take place as soon as the first tooth erupts and/or by the age of one year. 3 6 The total number and distribution of search results recommending similar guidelines were also considered, along with the scope of additional information available from those search results. RESULTS Online guidelines regarding timing for CFDV were readily accessible in the websites for five out of seven of the professional dental associations investigated, which consistently recommended the CFDV from when first tooth erupts (approximately six months old) to one year of age (Table 2). The professional associations and government agencies investigated from Australia and overseas had the same Table 3. Number and distribution of search results with accurate CDFV timings (and inaccurate CDFV timings) across the top 50 results in each search Search phrases Total Search rankings Baby first dental visit Child first dental visit Child dental care Baby dental care Top (8) 7 (1) 6 (2) 6 (2) 8 (1) 6 (2) 36 (4) 7 (1) 8 (0) 6 (0) 7 (2) 8 (1) 12 (8) 2 (2) 3 (1) 3 (2) 3 (2) 1 (1) 23 (6) 4 (2) 5 (2) 5 (1) 4 (0) 5 (1) guidelines, for the first visit by one year of age or from when the first tooth erupts. The sites which reported guidelines were private general dentists within Australia and parenting forums where comments were contributed by parents who were unlikely to be dental professionals. The availability and accuracy of search outcomes were keyword dependent. An analysis of the top 10 search results for each keyword revealed that child first dental visit and baby first dental visit yielded the most accurate information (with seven out of eight available guidelines being consistent with those recommended by professional dental associations) (Table 3). Baby dental care (four out of six sites recommended consistent CFDV guidelines) yielded slightly better search outcomes than child dental care (only two out of four sites recommended CFDV guidelines consistent with professional organizations) (Table 3). The pattern persisted throughout the first 50 search results (Table 3): child first dental visit yielded the most accurate search results with 36 out of 40 sites recommending the appropriate timing for CFDV, followed by baby first dental visit (33 out of 41), baby dental care (23 out of 29) and lastly child dental care (12 out of 20 search results). Forty-three duplicates were found in 200 search results (across the four phrases), leaving 157 unique sites. Among those, 74.5% of sites were contributed by privately owned sites (dental professionals accounted for 43.3% of the total) and 25.5% were public sites (Table 4). The timings for CFDV were available in 52% of the public sites and all were consistent with the international guidelines. In contrast, two-thirds (n = 81) of private sites recommended timing for CFDV but approximately one-third (n = 25) reported inconsistent guidelines suggesting an age range of 2 to 3.5 years (Table 4). Private sites primarily consisted of dental professionals (involving a quarter of all dental professional owned sites found, n = 17) and forums discussing parenting (n = 5) (Table 4). When the timing for CFDV was available, 2013 Australian Dental Association 279

3 CK Yeap and LM Slack-Smith Table 4. Analysis of sites: availability and accuracy of timing for CFDV recommended by various types of sites Sites Total Types of sites Public/corporate Private# Organization* Government Dental professional Non-dental professional CFDV not mentioned Similar to guidelines Dissimilar to guidelines Total contributing entries (25.5%) 117 (74.5%) *Organization includes corporate and professional institutions. #Private sites refer to sites owned by individual(s) who may be dental professionals (e.g. general dentist or paediatric dentist) or non-dental professionals (people who have not undergone dental training). Others Oral Habits <=4 Primary dentition Paediatric Dentist Reasons for Age 1 Dental Visit Anticipatory Guidance Fluoride Treatment Dietary Choices Dietary Habits Child Preparation Oral Hygiene Instructions Procedures for 1st visit Frequency (maximum:77) Fig. 1 Types of information available on sites recommending correct CFDV timings (n = 77). public sites had a higher accuracy of recommended timing for CFDV (100%) compared to private sites (69%) (Table 4). If all dental professional owned, organizational and governmental sites were considered to be authoritative, only 28.6% of all authoritative sites provided readily accessible guidelines on timing for CFDV that were consistent with international paediatric guidelines. An analysis of the ownership of 68 private sites owned by dental professionals revealed that only general dentists (n = 64) and paediatric dentists (n = 4) were owners and only 44% of those sites reported guidelines consistent with those recommended (Table 4). Depending on the search terms used, the recommendation of consistent timing ranged from 24% to 72% of the sites investigated (Table 3). An analysis of the other topics of information available in these sites revealed that the three most popular topics were oral hygiene instructions (45.4%), procedures for the CFDV (53.2%) and preparing a child for the CFDV (40.2%) (Fig. 1, legend Table 5). DISCUSSION A typical internet health information seeker usually starts his/her search at a search engine. 7,11 Hence, the study was conducted using Google, which was reported to be the most popular search engine in 2012, accounting for approximately 83% of internet users. 12 Based on subjective evaluation by eight non-medical personnel, recent research comparing the search results from Google with three other major search engines (Yahoo, Bing and Ask.com) using four keywords in the context of breast cancer concluded that Google had the highest search result validity (whether the webpage can be successfully opened), lowest inter-search result redundancy (duplication of search results) and the second highest score for the quality of search results (after Bing). 13 It was also reported that the average internet health information seeker feels reassured by advice that matches what he/she already knows and is repeated in more than one site. 7 In-depth interviews regarding the behaviours of internet surfing for healthcare Australian Dental Association

4 Internet information on child oral health Table 5. Explanation topics in Figure 1 Topic Procedures for 1st visit Oral hygiene instructions Child preparation Dietary habits Dietary choices Fluoride treatment Anticipatory guidance Reasons for age one dental visit Paediatric dentist Primary dentition Oral habits Others Information included Procedures for the first visit Toothbrushing (technique, when to start, when to assist), flossing (technique, when to start) Dos and Don ts before appointment, positive and negative reinforcement, role-modelling, systematic desensitization Nocturnal milk-feeding, non-spiller cups, overnight breastfeeding Cariogenicity of different food Fluoridated water, toothpaste, use of fluoride tablets Teething (signs, symptoms and pain relief), neonatal teeth, eruption sequence Reasons for age-one Child First Dental Visit Who is paediatric dentist? Difference with general dentist Introduction of primary dentition and its importance Use of pacifier, digit sucking, orthodontic impact Anxiety management (sedation, general anaesthesia) laser dentistry, role of a dental hygienist, caries (detection, role of plaque, risk assessment, parental transmission), early childhood caries and nursing bottle caries, sponsors of event/websites, access (location, eligibility, appointment booking), payment (options, rebates, offers, insurance covers), frequency of future recalls, treatment options and services available, concept of dental home, trauma management, indications for taking radiographs, fissure sealants information has revealed that an average internet visit usually involves two to five sites. 11 This highlights the importance of accurate online information being presented in the first 10 search results. In the current study, the search outcome was search-term dependent but reasonably consistent across the top 50 search results. Based on the average internet health information seeking pattern, the possibility of misinformation, although unlikely in the search results of child first dental visit, still existed for search results generated by the other three search terms. Depending on the search terms used, this study suggested that timing for CFDV on the internet was available for 40 82% of search results. When the accuracy of information was assessed, 24 72% of sites providing such information were considered accurate. These sites consisted of 21 public and 56 private sites (24 dental professional owned sites were included in the latter). The paucity of accurate information on CFDV guidelines on the authoritative sites was demonstrated by the finding that only 28.6% of all authoritative sites provided readily accessible guidelines on timing for CFDV that were consistent with international paediatric guidelines. This supports Edelstein s conclusion that information regarding child first dental visit is readily available and accessible, but not necessarily reliable and authoritative. 6 Nevertheless, the information regarding CFDV timing on public (corporate and government) sites was accurate (Table 4). Dental background of the author s occupation did not guarantee the availability and reliability of the suggested CFDV timing (Table 4). A quarter of the websites owned by dental professionals suggested CFDV timings that were at least 12 months later than the international paediatric guidelines. Further research is required to investigate the factors influencing the availability of recommended CFDV timing on their websites and their rationales for suggesting alternate timing for the CFDV. It may be useful for professional associations to consider whether they place such information on their sites or support it appearing on other sites. Although information presented on parenting related forums should be read with some level of scepticism, they may be the primary channels of information for many parents. Furthermore, if the average internet user judges the credibility of a website on the basis of the professional design rather than the about us section 11 then parents may not differentiate dental professional owned sites from parent forums and the likelihood of receiving misinformation may be increased. An informative site can be beneficial in promoting oral health literacy among parents. 8 Further investigation of the 77 sites which reported similar CFDV guidelines revealed that a wide range of relevant information was available. Apart from the recommended CFDV timing, the three most popular topics were procedures expected for the CFDV, oral hygiene instructions and child preparation for the CFDV, all of which could be useful in preparing both parents and children for a dental visit. Some topics that were overlooked, but could potentially promote paediatric dental vigilance, were dietary advice (dietary habits and choices), fluoride treatment (primarily via fluoridated water and fluoridated toothpaste) as well as anticipatory guidance (such as teething process and eruption sequence). Similarly, providing the reasons for the CFDV age one (16.8% of sites did this) and the importance of primary dentition (7.8%) could potentially encourage higher dental attendance for the age-one CFDV and maximize the preventive benefits of early dental visits. The lack of information regarding the differences between paediatric dentists and general dentists can be partially explained by the small number of paediatric dentistowned sites found in the study. Other educational topics (less than 6.4%) such as the significance and cessation of oral habits, the management of dental trauma, and the role of plaque in the development of 2013 Australian Dental Association 281

5 CK Yeap and LM Slack-Smith caries can be useful in the long-term dental care of the child. Overall, helpful information can be found in sites that provide the correct CFDV timing, although more comprehensive coverage of these topics on all sites could assist in promoting paediatric oral health literacy among parents. Some potential limitations of the study included the lack of reproducibility due to fluidity, inter- and intrasearch engine variability. Data collection was undertaken by searching the internet over the course of 17 hours. Unlike hard copies, information on the internet is constantly updated and re-ranked. This may have introduced some differences in the search outcomes due to the time-delayed effect. For the same reason, the results from the study cannot be projected to an identical study conducted at a later date. There are also concerns raised by Wang and colleagues about the different search focus of different search engines resulting in different search outcomes. 13 Moreover, intra-search variability may exist within the Google search engine as the study was conducted under the Australian domain and the location was predetermined as Perth, Western Australia. The search outcomes may have been tailored specifically to the residential location where the search was conducted. CONCLUSIONS In the context of the internet information for the timing of CFDV, public sites are more reliable than private sites and the dental background of the authors does not necessarily guarantee the accuracy of the information. There is relatively appropriate and consistent information available on CFDV but accessing it is keyword dependent. Future research is required to assess the reproducibility and generalizability of the results of the study, as well as the rationales for recommending alternate CFDV timing among some dental professionals. ACKNOWLEDGEMENTS The authors gratefully acknowledge financial assistance from the Undergraduate Research Grant 2010/11 provided by the Australian Dental Research Foundation and valuable editorial assistance from Julie Pegrum. REFERENCES 1. American Academy of Pediatric Dentistry. Policy on the Dental Home. Pediatr Dent 2006;28: American Academy of Pediatrics. Oral Health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics 2003;111: Nainar SR, Straffon LH. Targeting of the Year One dental visit for United States children. Int J Paediatric Dent 2003;13: Poulsen S. The child s first dental visit. Int J Paediatric Dent 2003;13: American Academy of Pediatric Dentistry. Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling and Oral Treatment for Infants, Children and Adolescent. Pediatr Dent 2009;30: Edelstein B. The age one dental visit: information on the web. Pediatr Dent 2000;22: Rice R. Influences, usage, and outcomes of Internet health information searching: multivariate results from the Pew surveys. Int J Med Inform 2006;75: Atchison K, Gironda M, Messadi D, Der-Martirosian C. Screening for oral health literacy in an urban dental clinic. J Public Health Dent 2010;70: Fox S. Pew Internet and American Life Project: The Social Life of Health Information, Washington: Pew Research Centre, Accessed 21 May Available from: aspx. 10. Gauld R, Williams S. Use of the Internet for health information: a study of Australians and New Zealanders. Inform Health Soc Care 2009;34: Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and indepth interviews. BMJ 2002;324: Purcell K, Brenner J, Rainie L. Pew Research Center s Internet and American Life Project: Search Engine Use Washington: Pew Research Center, Accessed 21 May Available from: Use-2012.aspx. 13. Wang L, Wang J, Wang M, Li Y, Liang Y, Xu D. Using internet search engines to obtain medical information: a comparative study. J Med Internet Res 2012;14:e74. Address for correspondence: Professor Linda Slack-Smith Oral Epidemiology School of Dentistry M512 The University of Western Australia 35 Stirling Highway Crawley WA Linda.Slack-Smith@uwa.edu.au Australian Dental Association