Clinical Decision-Making in Oral Health

Introduction

This essay will explore my nursing practice as a Well Child Tamariki Ora (WCTO) nurse and critically reflect upon my clinical decision-making within a primary healthcare setting in relation to oral health. I will use the model of evidence by Di-Censo, Cullum and Cilska (2008) and explore it’s five areas including clinical expertise, client preference, research evidence, clinical state and resources to help facilitate self-reflection in my clinical role. I will further explore Te Iritio Waitangi and how I can implement culturally appropriate care as a WCTO nurse. Finally, on reflection how I can reduce health inequalities within my clinical practice towards promoting best oral health outcome for all children.

Research Evidence

Early childhood caries (ECCs) and poor oral health are easily preventable however, it still remains to be one of the most prevalent chronic health issues in New Zealand and globally (Schluter and Lee, 2016). Oral health is more than having a good smile and has a significant effect on an individual’s functioning, overall health and quality of life (World Health Organisation (WHO), 2012). Good oral health enables normal functioning including smiling, chewing, swallowing and speaking (Schluter etl, 2016). Oral health is easily influenced by food preferences, health literacy level, socio-economic status, ethnicity and level of fluoride exposure (Schluter et al, 2016; Do, Scott, Thomson… et al, 2014). Research suggests an average of 40% of children under the age of 5 will experience tooth decay (Schluter etl, 2016). The impact from having poor oral health in early years is of life and often leads to health complications later in life if no intervention is provided (Schluter et al., 2016). Many of these children are effectively treated using local anaesthesia in local dental clinics; however, more children are being admitted to hospital for treatment of oral health concerns including dental caries, each treatment taking approximately 60 minutes under general anaesthesia (Hunt, Foster, Thomson, 2018). Where more than one billion dollars are spent each year by New Zealanders for the treatment of dental diseases because of poor oral health (Schluter & Lee, 2016).  In the 1990’s New Zealand statistics began collecting ECCs data, showing Maori children at the age of 5 years were more likely to have dental caries than non-Maori (Bach & Manton, 2014).

According to the MOH (2018) 61% of 5-year olds were free from dental caries had access to fluoride water compared to 60% in non-fluoride water supply areas. Both Maori and Pacific children had higher dental caries in comparison to other ethnicities. The mean number of decayed, missing or filled teeth (DMFT) among 5 year olds were significantly higher than 8 year old children. Pacific children were identified to have a DMFT of 3.2 per child, Maori mean DMFT of 2.8 compared to other ethnicities of 1.2 DMFT. Overall, statistics show little difference for caries-free children between fluoridated and non-fluoridated locations. While the use of fluoride alone will not be fully efficient in preventing dental decay, fluoridation will have oral health benefits when used with weekly brushing of teeth, frequent dental check-ups and eating healthy foods (Waikato District Health Board, 2016).

Fluoride helps saliva to protect the tooth enamel by demineralizing and promoting remineralizations and preventing plaque bacteria producing acid (Bach et al, 2014; Royal Society of New Zealand, 2014). Once other bacteria have introduced Streptocucus Mutans (MS), only good oral health can reduce the effects (Bach et al, 2014). Fluoride toothpaste and fluoride-containing community water supply are two major ways for individuals to benefit from fluoride. Fluoridation of wider community water supplies is considered to be the most cost-efficient strategy in preventing dental caries (Royal Society of New Zealand, 2014 & Waikato District Council, n.d.).

Children are susceptible to ECCs from their first tooth erupting, usually from six months according to the WCTO “My Health Book” (The Royal New Zealand Plunket Trust, 2017). The MOH (2016) recommends breastfeeding up to 6 months exclusively, while the WHO supports ongoing breastfeeding for up to 24 months. Nakayama and Mori (2015) discovered the impact of nocturnal breastfeeding on ECCs as saliva production decreases during sleep. Finding an increased ECC risk with breastfeeding overnight between the ages of 18 and 23 months and is more likely to occur if a baby is breasted more than 7 times a day following age 12 months (Nakayama & Mori, 2015). Breastfeeding remains gold standard for optimal health and growth however, how often and when a baby is breastfed can influence ECC developing. Breastfeeding is not the only issue, bottle-feed infants have a higher risk of developing dental caries due to nocturnal feeding practices (Gandeeban et al, 2016). Dental caries is often the result of a routine that includes bottle-feeding, or snacking before bed by parents as influenced by behavioural patterns, tiredness and convenience (Kitsaras, Goodwin, Allan, Kelly & Pretty, 2018). Furthermore, the choice of foods introduced from six months influences oral health for example, foods containing free sugars can create an imbalance and an acidotic oral environment that leads to dental decay (Bach et al, 2014).

Resources

Statistics clearly demonstrate ethnic inequalities where Maori and Pacific people experience poorer oral health outcomes in contrast to other groups, in-particular children of low socio-economic status groups (Waikato District Health Board (WDHB), 2016; & Bach et al, 2014; & Aung, Tin, Jelleyman, Ameratunga, 2019). In 2006, the New Zealand Government developed a vision to address poor oral health. The’ Good Oral Health for All, for Life’ document, aims to promote good oral health for all children including the youngest population of society to ensure everyone has equal and easy access to free dental services and dental care until 18 years of age (MOH, 2006). Dental care is publicly funded for all children up to 18 years of age in New Zealand. The goal of this program is to encourage good oral health from an early age so that oral health benefits can be achieved through dental dentists in schools, community and mobile clinics through access to public dental services up until by the end of Year 8. Enrolment age differs by region however, parents are urged to enrol their children as early as possible by contacting 0800 TALK TEETH (0800 825583) (MOH, 2017). Mobile dental clinics visit local schools and community areas on a regular basis, children can also be seen in one of the Waikids Dental Clinics in Hamilton (Waikato DHB, 2012). Eight newly refurbished clinics in the Waikato have been completed in in the past 10 years to provide a centralized service to enable mobile clinics to focus on rural and high-needed areas such as Huntly to reduce the significant inequalities and tooth decay found amongst Maori and Pacific children.

The Well Child oral health education begins around 5 months of age, this is when I ask clients whether their child have been enrolled in the dental service. Many parents do not seem to see this as a priority, as teeth have often not yet erupted. Subsequently, a further 1-2 visits are often needed before children are generally enrolled and have their initial dental assessment by core 6 or about 15 months. The MOH (2017) provides free dental treatment for children, including as necessary regular assessments, fillings and extractions. The Well Child visits provides a prime opportunity ensure all children are enrolled and not, with consent from the parents a referral can be sent to the community dental health service.

The MOH have created an Electronic Oral Health Record (EOHR) program in that supports the DHB providing oral health services. The system contains enrolment records and treatments provided for each client. The EOHR aim is to provide all children equal access and oral health (MOH, 2017).

In addition, the MOH (2012) developed Tatau Niho Maori (Oral Health of Maori) Spinning wheel, providing health professional valuable statistics as gathered from the New Zealand Oral Survey 2009 specifically for Maori. It is an easy and simple tool for health professionals that covers oral health conditions, protective factors, oral health services, and perceptions and impacts of oral status for oral health education (MOH, 2012). Health inequalities have been highlighted by the Te Ao Marama (The New Zealand Maori Dental Association), it is the vision for Māori to have equal health outcomes as non-Māori as promised under the Treaty of Waitangi (Te Ao Marama, 2018). The focus of oral health is reflected throughout the WCTO schedule from core 4 visit to the B4 School check (MOH, 2013). Following the New Zealand Health Strategy, the MOH (2008) developed a resource toolkit for health professionals specifically on oral health with the aim of early preventing and oral health promotion within clinical practice.

The initial oral health assessment commences around 5 months old at core 4 by the WCTO nurse who provides oral health education in partnership with parents with the aim of preventing poor oral health. The WCTO nurse should first assess the family’s health literacy level and adapt the strategy in providing health education to reduce barriers and ensure the family understands the information provided. Providing relevant information in reducing the risks associated with ECC’s, providing babies first toothbrush and toothpaste and effective techniques for brushing baby teeth and to encourage parents to enrol their child with the community dental service as per the WCTO Practitioner Handbook (MOH, 2013). The WCTO nurse directs parents to the WCTO My Health book (The Royal New Zealand Plunket Trust, 2017) that provides vital information on Oral Health, interactive tooth eruption chart and enrolment contact phone number. Children up to the age of 9 is recommended to have parental supervision and assistance as required when brushing their teeth (The New Zealand Dental Association, n.d.). Children are often introduced to solids between core 4 and 5, this is a prime opportunity for the WCTO nurse to discuss the importance of food choices and how foods containing free sugars can affect oral health. The WCTO nurse will continue to emphasize previous oral health education provided at core 5 (9 months old) and teach parents how to assess their child’s teeth using the “lift the lip” process and what to look for. Most parents are confident in knowing what to look for after being shown however, visual handouts may benefit some parents to support education in oral health (Barnett, Hoang & Furlan, 2016). Finally, the WCTO nurse should refer children who shows early signs of dental decay from level 2 and higher (6 levels of dental decay) to the community dental service provider (MOH, 2018a, p. 52).

Client Preference

The nurse is guided by the principles of partnership, protection and participation of Te Tirti o Waitangi (MOH, 2014). The WCTO nurse client relationship should be developed upon these principles to gain an understanding of their client’s needs and preferences. This practice reflects the principle 1.3 of the New Zealand Nursing Council (2012), which encourages listening to and respecting the client’s beliefs on health, and 2.2 supporting and understanding the clients language/culture, needs and preferences.

Oral health is easily influenced, behavioural practices, lifestyle and environment contribute to a parent’s decision making in their children’s health (Shearman, 2011). Parents are often influenced by what food the child prefers or will accept as well as the cost and convenience of preparing meals. Long term dietary habits and their oral health in adulthood is often the result of habits developed at a young age (Boak et al, 2016). Parents own oral health is often a potential indicator for the outcome of their child’s oral health (Dima et al, 2018).

Parents perception for or against fluoride continues to vary, questions are often asked about the importance and levels of fluoride in toothpaste. The MOH (2018) recommends the use full strength toothpaste containing 1000pp of fluoride for all ages to promote stronger teeth and reduce risk of tooth decay. Parents are often unsure of using this toothpaste for infants as parents believe toothpaste is not important as “their baby teeth will fall out and regrow” or that toothpaste containing 500pp of fluoride is readily available and developed for children. The Well Child nurse provides parents education based on the MOC (2013) WCTO Practitioner Handbook guidelines to use a smear of 1000ppm toothpaste until six years then increase amount to pea size alongside providing information to support the benefits of fluoride in preventing tooth decay, thus enabling parents to make an informed choice. By working in partnership with parents provides a good opportunity to further answer any questions the parent may have about oral health in order to be able to make an informed choice. Parents who encourage their children and establish good oral hygiene practices with their baby teeth significantly influences the child’s behavioural practice leading into adulthood and their overall oral health and general well-being (Shearman, 2011).

Clinical State

Huntly is a quiet town approximately 30 kilometres north of Hamilton comprising of two main suburbs, Huntly West and Huntly East. Huntly West main ethnic group comprises of Maori (70.2%), followed by European (38.7%), Pacific (8.7%), Asian (3.3%), Other (1.5%) (Statistics NZ, 2014). In comparison to Huntly East where the main ethnic group is European (70.3%) followed by Maori (32.8%), Pacific (6.8%), Asian (5.9%) and other (1.8%) (Statistics NZ, 2014). Huntly has a depravation index of 9 -10 meaning the most deprived (New Zealand Parliament, 2017). The median income for families in Huntly varies between $19,100-$50,000 and average of 28.8% to 36.3% less compared to the average income of the Waikato District (Statistics NZ, 2014a, Statistics NZ, 2014b).

Huntly is a lower socio-economic area with poorer oral health of children. As discovered, the percentage of Maori and Pacific living in low socio-economic area can impact on the oral health and general health outcome of children. Research supports families who live in low socio-economic areas are more likely to have lower education and incomes in which impacts upon their dietary choices and oral hygiene practice for example, brushing teeth twice per day with fluoride toothpaste (Shearman, 2011; Broughton et al, 2013). Children in lower socio-economic homes are more likely to commence oral hygiene practice at an older age, brush teeth intermittently and reduced access to oral health services (Bach et al, 2016; Do et al, 2014). While the oral health outcome of a child is highly influenced by their living environment, other important factors, including nutrition, parenting practice, education and culture play a crucial role (Shearman, 2011). It can also be a challenge for family’s access resources as they differ between lower socio-economic to higher socio-economic levels (Ha, Do, Luzzi, Mejia & Jamieson, 2016).

Huntly is a reduced-resource area where families are mostly considered medium to high needs, often resulting in requiring additional contacts for oral health education (The Royal New Zealand Plunket Trust, 2017. P. 19). Huntly has an increasing population of Maori, Pacific and Asian families, and additional resources could be useful to ensure that clients can comprehend the factors that cause dental decay and affect oral health (MOH, 2013a). During visits I have identified many young children with signs of dental decay in that a referral to the community dental service and general practitioner for further assessment and treatment. Children by the age of 5 continue to have high rates of dental decay. I have found by encouraging parents to contact the community dental service on 0800 TALK TEETH parents are enrolling their children, having attended an appointment and or enrolled (MOH, 2018). Many of my parents will require additional support, education and guidance throughout their oral health journey that’s where supporting services such as “Family Start” can work alongside and support such families, particularly first-time parents.

Clinical Expertise

The WCTO programme is a package designed to support the health of family/whanau and their children from birth to 5 years of age. It provides an important gateway for health screening, surveillance and clinical assessments to reassure parents their child is reaching expected developmental milestones, providing support and referrals to health care services as required (MOH, 2013a). The registered nurse’s role is defined as using nursing knowledge to assess the needs of individuals and their families then make a clinical judgement based on their knowledge, clinical expertise and practical experience (Nursing Council of New Zealand, 2016 & Krishnan, 2018).

The WCTO nurse gains extensive knowledge of the community in which they work in and are specialised in providing health education and care based on the Wellness model (MOH, 2018). As a registered nurse who has joined the Plunket organisation I am required to undertake the post graduate certificate in Primary Health Care Speciality Nursing which enables further understanding of the determinants of health determinants and the effects on health in relation to evidence based practice relevant to oral health (MOH, 2013a). The WCTO programme Practitioner Handbook (MOH, 2013) guides WCTO nurses in promoting oral health and the importance of good oral health for baby teeth for long term oral health. Brushing teeth by an adult until the age of five, using fluoride toothpaste twice a day. Good oral health education will provide parents with relevant information to enable good oral health practices with their child (MOH, 2013a; NZDA, n.d.).

Ross (2018) supports conflicting priorities prevent oral health promotion from being efficiently covered by nurses. During visits, time limitations in my experience do not allow sufficient emphasis to be provided on the significance of oral health care that needs to be covered. Significant advancement has been made, however, 40% of children still experience dental decay by the age of 5 (MOH, 2018).

On reflection, I feel it would be beneficial during the “lift the lip” physical assessment to utilise equipment such as a pen light for better visibility. I will also include referring to and utilising the “Healthy Smiles” videos as part of oral health promotion and education during the Well Child Checks. In addition, utilising the Colgate demonstration “mouth” to support parents who may have lower health literacy levels and learn better from physical demonstration.

Krishnan (2018) describes clinical decision-making as a best course of action for a client through observation, using information to problem solve to make a clinical judgment based on reflectivity and evidence-based practice. As a WCTO nurse clinical decision making and evidence-based practice enables to support families/whanau in a culturally aware manner. Broughton et al, (2013) research New Zealand oral health and investigated why Maori have poorer oral health outcomes, findings suggest a cultural-based approach may provide a better health outcome with anticipatory guidance. It is my responsibility to clearly demonstrate and document the clinical decisions I make based on the clinical assessment findings and the client’s needs (Magrath, 2015).

Conclusion

The Di-Censo, Cullum and Ciliska (2008) model of evidence-based decision making assisted to focus on the five crucial areas; clinical expertise, client preference, research evidence, clinical state and resources. I investigated my local community of Huntly and how lower socio-economic status can impact on oral health and the development of dental caries. Research supports poor oral health as during early childhood has a significant impact on oral health and general health later in life, however this can easily be prevented. WCTO nurses have a crucial role providing oral health promotion and education for parents of young children. I use the Te Tiriti o Waitangi principles to build relationships to provide evidence-based practice in a culturally appropriate manner to complete an oral assessment and provide relevant education and tools for parents to make an informed decision to achieve the best oral health outcome. The aim for Huntly families/whanau is to promote ongoing good oral health support and education towards their child’s oral health and general health outcome. 

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