How Dentists and Dental Hygienists in Alberta Frame the Issue

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2013-01-25 The Intersection of Early Childhood Caries and Domestic Violence: How Dentists and Dental Hygienists in Alberta Frame the Issue

Guardia Tello, Carola

Guardia Tello, C. (2013). The Intersection of Early Childhood Caries and Domestic Violence: How Dentists and Dental Hygienists in Alberta Frame the Issue (Unpublished master's thesis). University of Calgary, Calgary, AB. doi:10.11575/PRISM/28222 http://hdl.handle.net/11023/485 master thesis

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The Intersection of Early Childhood Caries and Domestic Violence: How Dentists and

Dental Hygienists in Alberta Frame the Issue

Carola Guardia Tello

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF MASTER OF SCIENCE

DEPARTMENT OF COMMUNITY HEALTH SCIENCES

CALGARY, ALBERTA

JANUARY, 2013

Abstract

This study explored points of view from dentists and dental hygienists in Alberta along with national and provincial experts in public health dentistry and domestic violence prevention about two important topics: Early Childhood Caries (ECC) and Domestic Violence (DV). Semi- structured interviews were used and the results showed a general consensus that dentists and dental hygienists do not consider that ECC and DV intersect. As a result, intervention at this level will be very difficult to implement, since the existence of the problem is not recognized.

This study identified gaps in practice, knowledge, education, research interest and intersectoral and interdisciplinary action that need to be addressed.

Acknowledgments

I would like to thank the individuals whom participate in this project, those who shared

their ideas and points of view openly.

To my great supervisory committee, for their insights and guidance during this lengthy

process. Thank you Dr. Vollman; Mrs.Maloff and Dr. Thurston. Your constant support and

encouragement was greatly appreciated.

A special thanks for Crystal Elliott and Kathy Dirk who helped me along the process.

I would like to thank my husband and sons, whom were always there for me, showing me

their support and love.

Finally, I would like to thank Tara and Janice, my friends, for their supportive words and kindness.

iii

Table of Contents

Abstract ...... ii Acknowledgments...... iii Table of Contents ...... iv List of Tables ...... vi List of Figures ...... vii Chapter 1. Background to the study ...... 1 Introduction ...... 1 Literature search and review ...... 5 Early childhood caries...... 5 Domestic violence ...... 7 Link between DV and ECC ...... 8 Role of dentists, dental hygienists and regulators re: ECC and DV ...... 10 Chapter 2. Research Design and Methods ...... 13 Research question ...... 13 Sampling ...... 14 Data collection ...... 15 Analysis and interpretation ...... 16 Ethics...... 17 Chapter 3. Results ...... 19 Description of participants ...... 19 Document analysis ...... 20 Legislation...... 20 Codes of ethics ...... 22 Policy documents ...... 24 Scopes of practice ...... 25 Position statements...... 26 Other documents ...... 27 Framing ECC ...... 29 Dentists ...... 29 Dental hygienists ...... 32 DV specialists ...... 33

Framing DV ...... 34 Dentists ...... 34 Dental hygienists ...... 37 DV specialists ...... 39 Intersecting ECC/DV ...... 43 Dentists ...... 43 Dental hygienists ...... 46 DV specialists ...... 47 Chapter 4. Discussion ...... 49 Framing ECC ...... 49 Framing DV and the intersection of DV and ECC ...... 51 Key results ...... 51 Gap in practice ...... 51 Gap in knowledge ...... 56 Gap in education ...... 60 Gap in research interest ...... 61 Gap in intersectoral and interdisciplinary action ...... 62 Opportunities for action ...... 63 Opportunities for practice ...... 63 Opportunities to fill the knowledge gap...... 63 Opportunities in education ...... 63 Opportunities for future research ...... 64 Opportunities for intersectoral and interdisciplinary action ...... 64 Significance of the study ...... 64 Strengths and limitations...... 65 Conclusion ...... 66 References ...... 67 Appendix A...... 78 Appendix B...... 82

List of Tables

Table 1. Participants of the study ...... 20

List of Figures

Figure 1. Bottle feeding as a protective factor against DV ...... 9

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Chapter 1: Background to the study

Introduction

Early childhood caries (ECC), also known as rampant caries, baby bottle tooth decay, nursing caries syndrome, among others, is a destructive type of caries that affects children’s primary dentition (Vadiakas, 2008). ECC affects the ability to chew food properly. The presence of ECC causes pain, crying, need for medications, and expensive and extensive treatments.

Domestic violence (DV) is also termed domestic abuse, spousal abuse, and intimate partner violence. Hegarty, Hindmarsh and Gilles (2000) define domestic violence as “a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse, such as social isolation and financial deprivation” (p. 367).

Framing connotes how a problem is defined, constructed, and communicated (Entman,

1993). Both ECC and DV have been framed separately by media, health professionals and the public. Nevertheless, there is anecdotal evidence that the issues are being linked in the minds of some prominent oral health professionals (e.g., Dr. Leonard Smith of Calgary) and are being featured in some media articles as linked (Cole, 2008).

The relationship between ECC and DV has not been established, and there is a paucity of literature on the topic. There are, however, some indicators that could suggest a higher prevalence of ECC in children who experience direct abuse, neglect or maltreatment (Valencia-

Rojas, Lawrence, & Goodman, 2008; Greene, Chisick, & Aaron, 1994). These studies

demonstrate a link between child abuse, neglect and ECC, and raise awareness of the need for

better screening and follow up of DV and the potential effects on children. Another group of

studies has been done with a focus on children of US military families (Greene & Chisick, 1995;

Greene et al., 1994); results showed a high prevalence of ECC in children identified as living

with DV.

ECC and DV are both subject to stigmatization and stereotyping. People tend to relate

ECC with poor oral hygiene and inadequate nutritional habits (Martens, Vanobbergen, Willems,

Aps, & De Maeseneer, 2006; Palmer et al., 2010). Although these two etiological factors play a

role in the development of ECC, they are not solely responsible. In the same way, people tend to

relate DV with mental illness (Choe, Teplin, & Abram, 2008) and substance abuse (Brackley,

Williams, & Wei, 2010) when this is not always the case; there are many other factors that could

influence violent behaviour such as social and economic factors, among others (Foege,

Rosenberg, & Mercy, 1995; Anderson & Aviles, 2006).

It can be speculated that a combination of factors, such as the determinants of health (i.e.,

income and social status, social support networks, education, employment and working

conditions, social environments, physical environments, personal health practices and coping

skills, healthy child development, biology and genetic endowment, health services, gender and

culture (Public Health Agency of Canada [PHAC], 2010) are associated with the prevalence of

both ECC and DV. With what is now understood about the determinants of health and their

implications for population health, the cause-effect relationship for many conditions (e.g., ECC) or issues (e.g., DV) is no longer a linear relationship between one risk factor and the disease,

issue or condition. It is becoming more urgent to examine DV and ECC together using the

determinants of health lens in order to understand if there is a link between the two and, if so,

where it is and when it occurs.

There are many gaps in the literature about ECC and DV together. Some studies linking

ECC and DV were carried out more than a decade ago (Blumberg & Kunken, 1981; Da Fonseca,

Feigal & Bensel, 1992; Greene et al., 1994; Greene & Chisick, 1995; Jessee, 1995; Rupp, 1998) .

Those studies suggested a possible association between ECC and DV. Done in 1981, a seminal study linked some children’s behaviour at the dentist’s office and untreated tooth decay with DV, and articulated signs of DV that could be recognized by dentists in their offices (Blumberg &

Kunken, 1981).

The link between child maltreatment and ECC is clearer than the link between DV and

ECC. Da Fonseca and colleagues (1992) investigated the frequency of injuries due to child maltreatment and found that 75% of injuries are to the head, face, mouth and neck, and also found that untreated tooth decay is a common occurrence in maltreated children. Three studies conducted between 1986 and 1995 in a specific population of abused or neglected children of military households (Badger, 1986; Greene et al., 1994; Greene & Chisick, 1995) had mixed results. Two studies found that children exposed to abuse or neglect tended to have between five and eight times the untreated tooth decay than children not exposed to abuse or neglect. There is some controversy about these findings, however. One study carried out in the same settings

(Badger, 1986) used two groups of children aged from 2 to 19 years old identified as “active cases of child abuse/neglect” (p.101). The study compared its results with the national means of the DMFT (Decay, Missing, Filled, Teeth) index from the 1965 Health Examinations Statistics

Survey, and found no significant difference in the incidence of caries between abused or neglected children from military households and their counterparts. Other studies postulated the need for intervention in cases of child abuse or neglect, and provided basic guidelines to the dental health team to identify and act when child abuse or neglect is suspected (Kellogg, 2005;

Harris; Sidebotham & Welbury, 2007; Lincoln & Lincoln, 2010). The most recent study in

Canada was conducted in central Canada and examined ECC and child maltreatment of children

in care; results suggested an association between ECC and the experience of child abuse and

neglect in this vulnerable population (Valencia-Rojas et al., 2008).

While dentists and dental hygienists are trained to examine and diagnose dental disease, they are not well trained in issues relating to DV. Giddon (2004) noted that dental professionals have the inclination to isolate themselves instead of integrating with the broader range of primary care health practitioners. However, as primary care workers, dentists and dental hygienists see patients closely enough to notice signs of DV. Dentists have opportunity to talk with patients privately about DV; however, according to some reports, their lack of training in recognition of signs of DV and other factors lead to underreporting of abuse cases (Bsoul, Flint, Dove, Senn, &

Alder, 2003; Lincoln & Lincoln, 2010; Harris et al., 2007). Barriers to reporting, according to

Littel (2004) include: limited knowledge of family violence issues; lack of practical experience on how to intervene; misconceptions about the nature of intervention; fear of litigation; lack of local referral information; the presence of a partner or children; concern about offending patients; and embarrassment about bringing up the topic. In Canada, Hendler and Sutherland

(2007) commented that of the many health professionals surveyed, dentists feel the least responsible for intervening in cases of DV, and interventions by dentists are minimal. Yet dentists are in an excellent position to identify and intervene in abuse.

Since ECC is a dental disease that affects children exclusively, this characteristic presents an invaluable opportunity for dentists and dental hygienists to intervene early where ECC may be linked with DV by reporting suspected child abuse or connecting adult patients and families with appropriate services for DV. Understanding how dentists and dental hygienists frame the potential link between ECC and DV and their roles and responsibilities in intervening would be a starting point in designing future studies and/or interventions connecting these two issues.

Literature search and review

In order to assess the status of research linking DV and ECC, the following databases were consulted: Social Work abstracts; Sociological abstracts; Family and Society Studies;

Family and Society abstracts; and PubMed. Key words used to search Social Work Abstracts included: caries and children or child or infant or infants; and domestic violence or spousal abuse, partner abuse. No results were found. When the key words were changed to domestic violence and caries or tooth decay or dental decay or cavities or nursing bottle syndrome and children or child or infant or infants, 24 abstracts were located. One was retained as relevant to the research interest. For searching the Sociological abstracts, Family and Society Studies;

Family and Society abstracts, the term Intimate Partner Violence (IPV) was included with dental health and family violence. Nine articles were located; one was relevant. To search PubMed the keywords were caries, tooth decay, dental decay and children, child, infant, infants and domestic violence, intimate partner violence spousal abuse, partner abuse. Twenty citations were obtained; citations were screened and those deemed relevant were retained (n=9). Subsequent searches using compound terms as domestic violence and oral health obtained 99 citations; 30 retrieved were retained.

Early childhood caries

ECC refers to tooth decay with multicausal etiology (Litt, Reisine, & Tinanoff, 1995) that can begin when the first teeth appear in infants and, if untreated, can involve all primary teeth

(Vadiakas, 2008). ECC mostly affects children under 5 years old, is one of the most infectious types of caries, and is a disease that can destroy primary dentition in a short period of time

(Vadiakas, 2008). The main causes of ECC are bacterial colonization; inappropriate dental hygiene; use of bottle feeding to sleep; and eating a diet rich in carbohydrates. The bacterial

5 nature of this process may result in a chronic infection of the teeth (Nisengard & Newman,

1994).

Because of the characteristics of the population (preschoolers with complex caries) most

ECC treatments have to be performed under general anaesthetic (Berkowitz, 2003); creating a burden for the health system because this type of surgery could delay other paediatric procedures that require general anaesthetic and increase waiting lists. In a report published by the Wait

Times Alliance in 2010, it is mentioned that the most common type of paediatric surgery under general anaesthetic is the one done for caries (Wait Times Alliance [WTA], 2010)

Furthermore, ECC creates a burden for the family, because oral health treatments are expensive and parents have to pay up-front when their children receive treatment. People without private insurance may prefer not to take their children to a dental appointment (Leake, 2006).

Family stress could be a direct result of this situation, there may be blaming, tension, and the adoption of new behaviours. Dental fear could influence some changes in children’s behaviour

(Gustafsson, Broberg, Bodin, Berggren, & Arnrup, 2010); creating stressful demands on parents, particularly during ECC remediation treatments. If social services are involved, there may be demands placed on the family from agencies. Early childhood caries is a problem that needs to be addressed because infection can have a negative effect on permanent teeth (Schroth, Harrison,

& Moffatt, 2009).

Moreover, ECC creates a non-healthy environment for children. It leads to school absenteeism and increased levels of social stress. It has debilitating effects on the development, speech, general health and self-esteem and well being of young children (Schroth et al., 2009).

ECC has a nutritional impact on children, affecting negatively their weight (Gaur & Nayak,

2011). Pain associated with ECC may also lead to the need for continuous pain medication.

Domestic violence

Violence is defined by the World Health Organization as the use of physical force or power with the intention of threat that could result in injury, death, psychological harm, or deprivation (World Health Organization [WHO], 2002). Rutherford, Zwi, Grove and Butchart

(2007) enumerate and define many types of violence including DV. The authors differentiate between DV and family violence, considering DV as interchangeable with intimate partner violence (IPV). Rutherford et al. (2007) view IPV as having four categories: physical abuse; verbal abuse; economic abuse; and social abuse. Family violence has categories of child maltreatment, sibling violence, intimate partner violence and elder abuse. Rutherford et al.(2007) consider that the terms DV and family violence could be used interchangeably since both terms refer to violence that can happen inside the family environment (Rutherford et al.,2007). Other authors identify intimate terrorism; violent resistance; situational couple violence and mutual violent resistance (Johnson, 2008) as categories of DV. While Nixon (2001) found that there is not enough evidence to affirm that the exposure to DV is harmful for children, more recent authors have suggested there are reasons for concern. Sousa et al. (2010) report that DV has long term devastating effects on the emotional development of children and it could lead to antisocial behaviour. Majer, Nater, Lin, Capuron and Reeves (2010) suggested that living with DV affects

children’s normal social and psychological development and the exposure to DV may affect

brain development early in life. DV might also lead to neglect and failure to provide the

necessities of life, such as medical and dental care. The Public Health Agency of Canada (2008)

included dental neglect as a form of violence against children (Public Health Agency of Canada

[PHAC], 2008)

Child neglect is defined by WHO as “the failure of a parent to provide for the development of the child – where the parent is in a position to do so – in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Child neglect is thus distinguished from circumstances of poverty; neglect can occur only in cases where reasonable resources are available to the family or caregiver” (WHO, 2002, p. 60).

The Canadian Incidence Study of Reported Child Abuse and Neglect (PHAC, 2008) reported that in 2008, neglect accounted for 28% of all cases of child abuse or maltreatment in

Canada. Neglect in the form of failure to provide medical attention accounted for 9% of all cases where neglect was substantiated (Statistics Canada, 2001). Children under the age of 5 accounted for more than 40% of the shelter population in Canada between 1998 and 2000 (Statistics

Canada, 2001). Between 2007 and 2008 approximately half of the women escaping DV were admitted to shelters with their children; 69% of these children were under the age of

10 (Statistics Canada, 2009). An important and alarming fact was that Alberta reported the highest rates for partner violence (26%) followed by British Columbia (23%) (Cohen &

Maclean, 2004).

Although violence is a public health problem (Foege et al.,1995), it is also preventable by some actions such as conducting research (to determine what causes violence, what increases the risk of violence), and by designing interventions with the purpose of modifying causal factors of violence (WHO, 2002; Mercy, Rosenberg, Powell, Broome & Roper, 1993).

Link between DV and ECC

Blumberg and Kunken (1981) suggested that ECC may be the result of mothers attempting to protect their children or themselves from DV. Mothers might feed their babies with

sugary fluids in their bottles or calm babies with cariogenic food for fear that a family abuser

will retaliate against them or their children. In this way, it can be speculated that bottle feeding to

sleep or to calm babies when they cry is a risk factor for ECC but it becomes a protective factor

against DV (See Figure 1).

Neglect becomes child abuse when the caregiver is informed about how to maintain oral

health and has been given the basic assistance to help their children (e.g., education, monetary

help, and transportation to dental appointments) and they opt not to care for them. Rupp (1998)

states the following: “Dental neglect, a common form of child maltreatment, should be suspected

if rampant caries and oral infection, bleeding and trauma persist after the obstacles of financial

aid and transportation are addressed” (p. 96).

Figure 1. Bottle feeding as a protective factor against DV

Even though the link between ECC and DV is not obvious, there is some evidence that children

experiencing DV have a high prevalence of ECC in their early years (Greene & Chisick, 1995)

and that ECC may be caused by caregiver efforts to prevent DV (Blumberg & Kunken, 1981). 9

Role of dentists, dental hygienists and regulators re: ECC and DV

One of the roles of dentists and dental hygienists in their practice could be the regular

screening for DV, and if it is suspected or confirmed then direct the patient to the appropriate resources. To do this, dentists and dental hygienists can adopt the Asking; Validating;

Documenting and Referring (AVDR) model developed by Gerbert and collaborators. This model’s main purpose is to address the issue of DV in health care settings and set the appropriate channels in order to intervene and connect patients with available resources (Gerbert et al.,

2000). Hendler and Sutherland (2007) adapted the original version of the model to dental care settings. They provided a guide on how to ask questions; how to validate and empower people living with DV by sending the message that DV is wrong; how to document signs and symptoms of abuse; and, how to refer patients to the resources in place.

The literature provides very specific policies of the dental regulatory bodies in Canada regarding how to act in cases of ECC (Canadian Dental Association [CDA], 2010). Preventive and therapeutic measures should include teeth restoration and increase the frequency of dental visits and use of topical fluoride (CDA, 2010). They recommend ECC be managed as a hygiene and diet problem. Injures in the oral cavity and facial structures, bite marks or bruises in children could be identified as DV, but in most of the cases the management is oriented to immediate patient care, and apart from asking “How did this happen?”, dentists and dental hygienists are advised to manage the situation in a clinical manner. For instance, with respect to prevention of orofacial injuries, the CDA position statement (CDA, 2005) suggests that dentists inquire about the nature of the injury and the use of oral/facial protection. There is no link made between DV and orofacial injuries or between DV and ECC in any CDA statement. The lack of such a statement could mean that ECC and DV are not being framed as related in any way by this

10 national association of dentists. If this is the case, this study could be a starting point for research on the intersection of ECC and DV.

Love et al. (2001) found that 87% of dentists did not screen for DV and even when visible signs of DV were present, 18% of dentists still did not ask questions about DV. The same study reported that barriers to asking about DV were: presence of another person with the patient

(77%); lack of training in recognizing DV (68%); and concerns with offending patients (66%).

Patients’ cultural norms and customs accounted for more than half of the perceived barriers

(53%) and dentists were embarrassed to talk about DV with the patient (51%). Further, dentists reported that they lacked information about referral agencies (41%), lacked time to raise their concerns about DV (36%) and believed that patients would ignore their suggestions (29%).

Hendler and Sutherland (2007) identified the need for screening for DV in dental settings and the need for adequate protocols to be in place when a DV case is suspected. They based their recommendations on the fact that the vast majority of dentists (94%) do not have written protocols for addressing the issue of DV in their offices and their idea of an intervention is to make a note in the patient’s chart about what is suspected or confirmed (64%). Only a handful of dentists (13%) will help a patient by referring him or her to the appropriate resources (Love et al., 2001).

There is a gap in the literature and research on the subject of a link between ECC and

DV. When DV and ECC intersect, how do dentists and dental hygienists think about it? How do they frame the issue; that is, what are their central organizing thoughts about problem definition, causal interpretation, moral evaluation, and treatment or intervention recommendations? Is the intersection of ECC and DV an issue of concern? If so, how urgent is the issue and what sorts of factors contribute to understanding it? If it is neither an issue of concern nor an urgent situation,

11 why not? In attempting to understand the problem and its severity or urgency, dental professionals, the media, and the public will no doubt refer to the regulatory bodies of the two key dental professions for guidance. What do these institutions offer for understanding the intersection of DV and ECC? What do leaders in the paediatric dentistry field, the leadership of the oral health services in Alberta, and experts in domestic violence contribute to the understanding of the potential links between ECC and DV?

Chapter 2: Research Design and Methods

In this chapter, the research design, objectives and the methodology used to approach the research questions are presented. It will be also mentioned the sampling strategies used to choose our participants, how collection and analysis of data were done; and what strategies were utilized to provide trustworthiness and reliability to this study.

Research question

The primary research question was: How is the intersection of early childhood caries

(ECC) and domestic violence (DV) framed by dentists, dental hygienists, their regulatory bodies, oral health professional leaders and domestic violence experts in Alberta?

Secondary research question:

What regulations, policies, and protocols are in place in Alberta to guide dentists and dental hygienists when ECC intersects with DV in their client populations?

The proposed study was exploratory and descriptive and used a qualitative research design to address the objectives of the study:

1. To describe how dentists and dental hygienists frame the relationship between

ECC and DV;

2. To explore the knowledge of dentists and dental hygienists about the intersection

of ECC and DV as provided by educational leaders for the two professions of

interest;

3. To examine regulations, policies, and procedures of regulatory bodies,

professional associations and dental leaders in Alberta Health Services regarding

ECC and DV (separately and together); and

4. To explore how experts in the DV field in Alberta view the intersection of ECC

and DV.

Sampling

Purposive sampling and simple random sampling was used. It was expected that this

approach would yield a sample of 20 to 22 participants. Purposive sample was used to recruit

participants that were called key players, and could give us their insights about the intersection of

ECC and DV. We recruited 12 participants from this approach, divided into four groups: 1) those

that held a position in a regulatory body; 2) educators of oral health professionals; 3) experts in

DV; and 4) oral health leaders. Simple random sampling was used to recruit practising dentists

and dental hygienists. We use a dice to generate a number and choose every third name in the phone book. We sent recruitment letters to those. The number of dental hygienists was limited, so the sampling frame was very small. By using the phone books for Calgary, Red Deer and

Edmonton we established a simple random sampling frame, which yielded only one participant instead of the expected 6 dentists and three hygienists. No dental hygienist from the randomly chosen sample agreed to participate although many attempts to contact them were made. We called all people chosen in the sample. Dental hygienists were sent the information by mail and e-mail as well, with the current location of their practice, obtained from the CRDHA webpage, and we receive only one answer, this person was at first willing to participate, but then she discontinued her communication with us. We used regular mail, e-mail and telephone to try to reach participants. We left many messages and voice mails. All the participants that agreed to participate after we mailed them a letter of invitation were to set up a time for the interview and were sent consent forms for signing and return. Some consent forms were either faxed back to

14 us, to a confidential fax number, or e-mailed back to us. All participants consented orally on the record. The consent form is located in Appendix A.

Nine interviews were conducted by telephone, using a landline; one was conducted in person. One of the participants was using a cell phone; that interview provided poor sound quality and thus transcription was difficult. As a result, it was one of the shortest interviews.

After this experience we did not to schedule an interview if the interviewee was going to use a cell phone. For most of the interviews we used a telephone equipped with speaker. We also prepared for every interview by researching participants’ roles, rehearsing questions beforehand, and consulting with the transcriptionist about the quality of previous interviews. She informed us if the sound quality of the interview was poor; in this manner every interview became an improved version of the previous one. All interviews were transcribed verbatim.

A Blackboard site was set up in order to exchange securely the audio files and transcribed notes with the transcriptionist. Interviews were deleted from the Blackboard exchange site once the process of transcription was complete. Interviews were kept secure in a password protected memory key that was kept in a secure location when not in use.

Notes were written after every interview was completed, taking note of the participant’s mood and tone of voice. Notes were kept about the development of this project, the difficulties that we were experiencing, how to overcome these difficulties and if there were any new courses of action to follow. E-mail communications with possible participants and participants of this study were also kept since the beginning.

Data collection

Data were collected through document collection and review and semi-structured interviews. An interview guide was used for the interviews (Appendix B).

1. Analysis of the following documents was done: scopes of practice, codes of ethics,

position papers, and legislation relevant to the topic.

2. Semi–structured interviews were conducted by phone or in person depending on the

availability of the interviewee. Before the semi-structured interviews took place,

consent for participation, recording and use of recorded material were sought from

the interviewees.

Analysis and interpretation

The complete interviews were transcribed. An iterative approach was used; the

recordings were transcribed as soon the interview was completed. Data analysis followed the process outlined by Creswell (2003); data were organized and prepared for the analysis; extraction of general ideas was done and those ideas were coded; settings were described and data were interpreted (Creswell, 2003). For the purpose of this research, descriptive coding was used to allow the researcher to “access knowledge about the respondent ... or context, when seeking patterns, explanations and theories” (Morse & Richards, 2002 p.116). The software

NVivo7™ was used to assist with the data analysis. Interviews were conducted after the document analysis was complete so that the interviewer was aware of the policies, protocols and regulations governing dentists and dental hygienists regarding ECC and DV.

The validity or trustworthiness of the study was assured using three strategies outlined by

Creswell (2003); triangulation, prolonged time in the field and clarifying researcher bias. Morse and Richards (2002) defined triangulation as “the gaining of multiple perspectives through completed studies that have been conducted on the same topic and that directly address each other’s finding ... a researcher may do this by juxtaposing analysis of different data types and methods to illuminate the same question” (p. 76). Multiple sources of data were used: 1) semi

structured interviews from a variety of participants with different points of view about ECC and

DV; 2) documents and policy statements from multiple sources; and 3) field notes. The

observations were not discussed with anyone until they were ready to be analyzed. The

researcher kept a parallel set of notes for the reflective part of the experience; in these notes the

researcher included “thoughts, confusions, and understandings of personal, methodological, and

analytic aspects of the fieldwork experience” (Crabtree & Miller, 1992; p. 63).

Prolonged time in the field was accomplished by taking an intensive approach to

interviewing participants. Interviews were conducted in such a way that interviews of

participants with similar interests were separated by interviews of participants with potentially

varying points of view. To minimize or clarify any potential preconceived notion the researcher

brought to the study as a result of her dental training, an honest reflection outlining the ideas that

the researcher had about the ECC and DV and the intersection of the two issues was carried out by using a reflective journal. The researcher debriefed regularly with the supervisory committee.

The researcher put aside her personal beliefs so she could be free to describe and comprehend the issues that have been investigated.

Reliability or dependability was assured by using an audit trail so “complete records are kept for all phases of the research: process-problem formulation, selection of research participants, fieldwork notes, interview transcripts, data analysis decisions ... and (all of these records) will be accessible” (Bryman, Teevan & Bell, 2009, p. 133).

Ethics

The Conjoint Health Research Ethics Board (CHREB) approved this study (Ethics ID: E-

23640). Documents used for the study (scopes of practice, codes of ethics, position papers) are in

the public domain as a result there is no risk of unauthorized use of these documents. The study

17 participants provided informed opinion to develop an understanding of how the issues are framed. Anonymity of the participants was assured by obscuring identities and using numerical identifiers. The list of numbers and names are held in a secure location in a locked file. Any quotes were anonymised. Recordings were uploaded to a safe Blackboard site and after transcription were transferred to a password protected file on a password protected computer stored in a locked cabinet when not in use. Recordings were erased from the recorder once uploading was successful. Any paper (e.g., consent forms) was scanned and stored as described above upon which time the paper was shredded. All files will be stored on a password protected memory stick in a secure file located in a locked drawer for 7 years, then destroyed according to the University of Calgary Faculty of Medicine policy. Any risk of unauthorized external or internal access to identifying information through storage has been mitigated by the use of password protected equipment and secure electronic storage. The risk of accessing information through inadequate disposal of documents was mitigated by shredding.

Chapter 3: Results

In this chapter we present the results of this study. This chapter is presented in six

sections. In the first section we give a description of the participants. The second section is

centred on the documents gathered for the purpose of this study; we describe documents that are

related to the legal obligation that health professionals and others have when they suspect abuse,

neglect, and /or DV. The third section is about framing ECC, using the lenses of dentists, dental

hygienists and experts in DV. In the fourth section we explore the views of participants with respect to DV that is, how they define and conceptualize DV. The fifth section is entirely dedicated to explore the intersection of ECC and DV in the views of our participants; it forms the key part of this study and provides insights to address our primary research question. The sixth section is dedicated to concluding statements about the results obtained.

Description of participants

The final sample consisted of 13 participants, nine females and four males (Table 1) who participated in 10 semi-structured interviews; two of them being a group interviews. Eleven of

them were either dentists or dental hygienists who were in practice or had been in the past. Two

of them had a background in another discipline. Participants were assigned codes: P1to P7;

including P9; and P8 and P8.1 (group interview); and P10, P10.1, P10.2 (group interview)

Table 1. Participants of the study

Participant Role Number Sex and Location Dentists, paediatric 1 1 female, Alberta

Professional regulatory 2 2 females, Alberta. representatives Educators 4 1 male, 3 females, Alberta. Oral health leaders 4 2 males, Alberta, 1 male, 1 female, Canada. Experts in DV 2 2 female, Alberta.

Document analysis

The results of the document analysis are presented in three sections: review of legislation relevant to the health professions; codes of ethics of dentists and dental hygienists; scopes of practice of dentists and dental hygienists; and policy documents relevant to the two professions of interest.

Legislation

In Alberta, there are legal documents created with the purpose of protecting children and families from violence, and to make health professionals accountable of their actions with regards to people under their care. The Child, Youth and Family Enhancement Act (2004) is a piece of legislation intended to protect children from harm. It provides working definitions of neglect and emotional injuries. According to this legislation if anyone believes that a child or children are in a situation where their “survival, security and development” (Child, Youth and

Family Enhancement Act, 2004) are at risk, it must be reported. And it is very clear about the definition of neglect:

A child is neglected if the guardian

(a) is unable or unwilling to provide the child with the necessities of life, (b) is unable or unwilling to obtain for the child, or to permit the child to receive, essential medical, surgical or other remedial treatment that is necessary for the health or well-being of the child, or (c) is unable or unwilling to provide the child with adequate care or supervision (Child , Youth and Family Enhancement Act, 2004, p. 11)

A child is emotionally injured if there are reasonable and probable grounds to believe that the emotional injury is the result of

(A) rejection, (A.1) emotional, social, cognitive or physiological neglect, (B) deprivation of affection or cognitive stimulation, (C) exposure to domestic violence or severe domestic disharmony, (D) inappropriate criticism, threats, humiliation, accusations or expectations of or toward the child, (E) the mental or emotional condition of the guardian of the child or of anyone living in the same residence as the child; (F) chronic alcohol or drug abuse by the guardian or by anyone living in the same residence as the child (Child, Youth and Family Enhancement Act, 2004, p. 11)

A child is physically injured if there is substantial and observable injury to any part of the child’s body as a result of the non-accidental application of force or an agent to the child’s body that is evidenced by a laceration, a contusion, an abrasion, a scar, a fracture or other bony injury, a dislocation, a sprain, hemorrhaging, the rupture of viscus [related to abdominal trauma], a burn, a scald, frostbite, the loss or alteration of consciousness or physiological functioning or the loss of hair or teeth (Child , Youth and Family Enhancement Act, 2004, p. 12).

This Act states that if someone fails to inform about a child in a vulnerable situation, the government can issue a fine against the offender (i.e., the person who failed to make a report).

The Act also states that the person who reports will not have action taken against him/her unless the report is malicious or done without foundation. Anonymity and confidentiality are not granted by this Act. A person who makes a malicious report is subject to a fine. If the offender is a health professional, the offence could be reported to their regulatory body for sanction as well.

Jail time would apply if the offending person does not pay the fine. Furthermore, witnesses of cases are obliged by this Act to provide evidence in court.

Codes of ethics

Codes of ethics are a set of guidelines that people who practice a profession are expected

to follow. A code of ethics, used in conjunction with professional standards, laws and regulations

that guide practice, provide guidance for ethical relationships, behaviours and decision-making.

Dentists and dental hygienists have their own codes of ethics.

Dentists

In Canada, The Canadian Dental Association (CDA) code of ethics is the source of many

other oral health professions’ codes of ethics across the country, each provincial; regulatory body

has similar guidelines in their own codes of ethics. The CDA code of ethics summarizes the

responsibilities that the dentists have to their patients, public, profession and colleagues.

Although the general health of the patient is mentioned as the primary concern for a dentist, this

code is very business oriented, mentioning cost, aesthetic values, fees, compensation for

services, market advocacy, among other business-like activities. The main responsibility of the dentist is the well being of the patient, and this is emphasized through all the code, but the primary concern seems to be the service provider point of view. Confidentiality was mentioned in this document; any information that is obtained from a patient is considered confidential, unless there is a law to the contrary (e.g., child protection acts).

According to this code, dentists are encouraged to “participate in health promotion programs that are in the best interest of the public and supported by the profession” (Canadian

Dental Association [CDA], 1991). Other than the imperative for health promotion (located in

Article 3 that refers to advertising), the code contains mostly generic information about responsibilities, services, duties and treatment. Explicit information about specific situation and diseases are not mentioned in the code, including any reference to DV or ECC.

There is an interesting excerpt from the code that could be easily related to the subject of

this study: “Dentistry is a profession, in part, because the decisions of its members involve moral

choices. Every dental practitioner makes decisions that involve choices between conflicting

values while providing care for patients” (CDA, 1991).

The Code of ethics of the Alberta Dental Association + College (ADA+C) takes serious

issues into consideration, such as the dentist’s duty to report child abuse. It makes dentists accountable for not reporting: “A dentist is obliged to become familiar with the signs of child

abuse and to report suspected occurrences of child abuse to the proper authorities in compliance

with Alberta laws” (Alberta Dental Association and College [ADA+C] , 2007).This code

acknowledges the role of dentists as primary health care providers. As per the CDA code of

ethics, confidentiality can be breached if required by law. An important addition is that patient

information “verbally, written or electronically acquired and kept by the dentist, shall be kept in

strict confidence except as required by law or as authorized by the patient” (ADA+C, 2007). This

code does not contain any reference to ECC, but it contains a direct reference to DV in the form

of child abuse.

Dental hygienists

Canadian Dental Hygienists Association (CDHA) code of ethics states that the main

responsibility of the dental hygienist is “to the client” (Canadian Dental Hygienist Association

[CDHA], 2002). This code was divided into five sections, each corresponding to a principle that

dental hygienists must use to guide their professional behaviour. These principles are

beneficence; autonomy; privacy and confidentiality, accountability; and professionalism.

Privacy and confidentiality are explained more deeply in this code. The dental hygienists’

code of ethics states that there are some exceptions to dental hygienists holding patient

information in confidence: if they are required by law to disclose it, and if the information that

they are going to disclose will prevent harm. Those two exceptions are especially important in

cases where the dental hygienist comes across DV instances in their practices. This code

acknowledges that dental hygienists are accountable for every action that occurs during their

practice but does not contain any specific reference to DV or ECC.

The College of Registered Dental Hygienists of Alberta (CRDHA) code of ethics uses the

word “client” instead of “patient” and refers not only to an individual but sometimes also to the

community. This code adds the notion of determinants of health and the effect on the overall oral

health of individuals/communities. As well as the code of ethics from the ADA+C, this code

acknowledges the duty to report abuse; in its Principle 1.9, this code states that “dental hygienists are familiar with the signs of client abuse and will report suspected client abuse cases to the proper authorities in compliance with Alberta laws” (College of Registered Dental hygienists of

Alberta [CRDHA], 2007). Privacy and confidentiality are included in the code of ethics, and holds that any confidential information should be kept private unless required by law or there is

the possibility of “significant risk or harm to the client or other persons” (CRDHA, 2007).

Policy documents

The research proposal included a set of document for further review, such as: scopes of

practice, regulations, position papers, AGM resolutions and policy statements from both the

Alberta and Canadian professional/regulatory bodies within the past 5 years. However, some

documents were impossible to obtain. We have some information that stated that most of the

documentation required was available only to the members the College, and cannot be accessed

for research. Certain documents were gathered from the internet, but were disregarded based on

the fact that not being directly posted in the web page of the professional associations, the

24 information was not verifiable. Documents from the CDA were not available to the public, only for members. When we started this project we had access to some AGM reports from 2007 and

2008 that were accessible by browsing the web; as we could not find any other AGM report, we requested AGM from the past five years to the CDA that were not provided, because the CDA resolutions remain between the attendees and the CDA stakeholders (D. Jolicoeur, personal communication, March 02, 2011).

Scopes of practice

The scopes of practice of the dental professions are based on what is contained in the

Health Professions Act. Schedule 7, in the Health Professions Act (2000) establishes that dentists in their practice: “(a) evaluate, diagnose and treat, surgically or non surgically, diseases, disorders and conditions of (i) the mouth, which includes teeth, gums and other supporting structures, (ii) the maxillofacial area, which includes upper and lower jaws and joints, and (iii) the adjacent and associated structures of the head and neck, to maintain and improve a person’s physical, psychological and social health, and (b) provide restricted activities authorized by the regulations”

The Health Professions Act (2000), Schedule 5, establishes that dental hygienists perform the following: “(a) assess, diagnose and treat oral health conditions, through the provision of therapeutic, educational and preventive dental hygiene procedures and strategies to promote wellness, (b) provide restricted activities authorized by the regulations, and (c) provide the service described in this section as clinicians, educators, researchers, administrators, health promoters and consultants.”

The Health Professions Act (2000) describes the role of dental hygienists as prevention and health promotion and the dentists’ role as improvers of physical, psychological and social health.

Position statements

Three position statements and one position paper were analyzed for the purpose of this study; early childhood caries, personal data protection, prevention of traumatic oral facial

injuries, and sports mouth guards; the first three belong to the CDA, and the last one to the

CDHA. The position statement about early childhood caries recognized ECC as a disease with

complex etiological factors. What is important to note is that there is recognition of other factors

outside the traditional way of thinking, such as the influence of the determinants of health, and

the profound influence of ECC in the life of children, their families and communities, and the

subsequent burden for the health care system (CDA, 2010). The position statement about

Personal Data Collection explain the need consent for the records to be released. It reaffirms

what is stated in the code of ethics, that even though patient records are confidential, if they are

required by law, they should be released (CDA, 2007). The position statement about Prevention

of Traumatic Oral Facial Injuries address the issue of the possibility of having oral facial injuries

as strictly related with sports activities and the prevention of injuries by using oral protection

(CDA, 2005). The CDHA has a position paper on mouth guards to prevent injuries; it too is

related only to sports injury prevention (CDHA, 2005). There are no DV position statements or

indication that DV or violence should be ruled out when considering ECC or traumatic injuries

to the face/neck structures.

Other documents

Responding to Child abuse: A handbook

This document, prepared by the Government of Alberta (2005), outlines procedures and

specific roles for people who work around children, including health professionals. These guidelines contain important information about reporting abuse. It is a complete guide, and it was the result of a conjoint work of physicians of the former Calgary Health Region, the Calgary

Criminal Justice Committee for the Investigation of child abuse and the Canadian Society for the

Investigation of child abuse. This document explains the obligation to report:

Health professionals and other health personnel have a responsibility to be aware of the indicators of child abuse. Because of their knowledge, expertise and frequent contact with children and families, health professionals are often in a position to recognize when a child might be in need of intervention services. As well, they can offer information and support to parents/guardians about health and safety for their children. All health professionals are required by law, and their individual codes of ethics or codes of conduct, to comply with any legislation regarding the reporting of child abuse and refer any incompetent, illegal or unethical conduct by colleagues or other health care professionals to the appropriate authorities (Government of Alberta, 2005, p.23).

The document also includes the information to record and what action to take in the

event of disclosure of abuse:

Health professionals, while continuing to support, should not interview the child about the abuse after receiving the child's disclosure. When reporting to a caseworker, health professionals and personnel should provide the following information: their name; their telephone number; their relationship to the child; any immediate concerns about the child's safety; the location of the child; the child's name; the child's address; the child's age; the name and address of the alleged perpetrator and any other identifying information; when and where the alleged incident took place, if it is disclosed by the child; a description of the indicators leading the health professional to believe a child is in need of intervention services. Any additional concerns about the child's safety. (Government of Alberta, 2005, p.23-24)

This handbook proposes guidelines structured by the Child, Youth and Family

Enhancement Act. The handbook also contains multidisciplinary guidelines for the investigation of child abuse for physicians and medical personnel.

Family Violence Handbook for the Dental Community.

This handbook prepared by Denham and Gillespie (1994) and published by Health

Canada presents straightforward information about family violence, how this is related to the dental community, what is the role of dental professionals when they deal with DV, and what should be the role and actions of the professional associations. Their suggested initiatives included:

...Training for all members of the dental team on family violence issues such as: child abuse legislation and reporting procedures, recognition of abuse indicators, communication skills for talking about abuse, treatment implications for patients/clients who are survivors of abuse; community resources for survivors of abuse ... Include routine questions about abuse as a part of the medical history (Denham & Gillespie, 1994, p. 24)

For professional associations their suggestions included:

Offer workshops on family violence at dental conferences ... support the integration of family violence issues into the education programs for all dental health professionals ... build interdisciplinary links with other professionals associations addressing family violence issues (Denham & Gillespie, 1994, p. 26- 27).

It also recognizes the existence of different parental practices that can affect oral health outcomes, but this cannot discourage health practitioner to not to act is abuse if suspected:

Many cultures have different child rearing practices which may affect the dental team’s understanding or recognition of abuse ... Understanding these differences is important in order to develop a relationship of trust and respect and to question patients more sensitively if abuse is suspected. Cultural differences should never be an excuse for inaction (Denham & Gillespie, 1994, p. 6)

In summary, the most important finding of this document review is that there is a strong

legal base that requires health professionals, including dentists and dental hygienists, to report any suspicion of abuse. Even though privacy and confidentially are respected, the law regarding reporting abuse goes beyond any other pre-existing right of privacy and confidentiality. It is also important to note that there is documentation prepared by institutions, and conjoint and multidisciplinary efforts of people from different backgrounds including dentistry, that recognize the importance of prevention in relation to violence.

Framing ECC

Dentists

Common concepts and definitions about ECC that differed little from the standard descriptions offered in the literature were shared by our participants. The presence of ECC is seen as a very serious problem affecting children, and the ideas expressed by many of our participants showed that ECC is a significant problem for the dental community in general, and that its etiology is determined by factors that are mostly not related to neglect. Although neglect is mentioned by some participants, it is considered for others as not significant to ECC:

... I look at it [ECC] more as ignorance or lack of knowledge ... perhaps lack of resources, lack of access to care ... I don’t look at it as a neglect problem on parent’s part. It can be in some instances but I look at it more as being a lack of knowledge or a lack of access to care (P2 L140)

... improper night time feeding habits ... lack of awareness on the part of the parents regarding how to avoid early childhood caries for their little kids ... (P9 L108)

Multifactorial explanations of the etiology of ECC where discussed; our participants considered that that there are some other factors in the etiology of ECC that have to be take into consideration (e.g., education, and hygiene, diet, among others):

... most of these parents [parents with children with ECC] are not well educated, so they think that ... because they’re losing all these baby teeth, then they don’t need assistance or they don’t think that it is important. They have other things, and other issues, that are more important... (P10 L 281)

... You have biological risk factors for example diet or hygiene, those things. We have non-biological risk factors ... it’s not that one single factor that you can differentiate it from other factors (P10 L292)

Cariogenic agents in the form of sugary fluids were added to the list of etiological factors mentioned by the participants (P4 L73). Treatment for caries as a first response was mentioned as well (P5 L65). Parents having multiple jobs, unable to lose a night of sleep and therefore putting the babies to sleep with a sugary bottle (P10 L 346) were considered a possible reason to explain why children have untreated ECC. Inexperience in dealing with children with ECC was included in the list; the idea that first time parents were unexperienced and do not know how to

prevent caries:

... You’re learning on this first child and hopefully your next child won’t have these problems (P10.1 L376)

The perspective/opinion that health professionals gave mixed messages about teeth care

was also explored. One participant pointed out that dentists, pediatricians and public health

nurses sometimes provide conflicting advice for cases of caries; they also differ in when is the

best time to take children to the first dental visit. Participants were of the opinion that if all child

health care providers promoted the same information about oral care, the outcome would be

better dental health:

... the kind of nutrition [for the child] was not good enough so the pediatrician, recommended like put the food everywhere and she, the Mom, was telling me that “ my child was nibbling all the time, like from the early morning to late afternoon” and she said ... she had to put the child through general anesthesia, for a general anesthesia to fix the teeth and she, she said she has no idea like just nibbling, they never mentioned so basically the information that they received from the physician was not really similar to the information that the dental

practitioner was providing so she kind of blamed the physician for not being concerned about the child’s dental health. (P10 L386)

... the current recommendation is taking a child to a dentist six months after eruption of the first tooth and no longer than one year old and we are trying to promote the early dental visit but ... many of our practitioners, they are not aware of it so again like if you can bring all health care providers to the same place and promoting similar information, then the outcome might be much better (P10 L406)

... And we also have a lot of work to do with the dentists because most dentists won’t see a child before three years of age because, ah, the little kids can’t sit in there, the dentist is probably more afraid than what the child is... (P10.1 L417)

The lack of government involvement in public health was mentioned by one of our participants, mentioning that there is work done by health professionals but more work and money needs to be invested in oral health:

... We have a lot of work to do on, on this point ... pediatricians are getting better but again there’s not a lot of pediatricians ... public health nurses take a look at the teeth to see if there’s any white spotations [sic] and if there is refer them to the dental department and the public health department ... the government is reluctant to spend more money even though they, they could have saved money in the long run. (P10.1 L423)

Under the lenses of one of our interviewees children’s health is not as important as other topics for the dentistry profession, especially for the regulatory bodies, who are more interested in providing continuing dental education in subjects that are in more demand for dentists, as courses that promote oral aesthetic

... you have different associations like the Edmonton Dental District and Dental Society, the same in Calgary ... they bring in speakers but they bring in speakers that are, there are various speakers that come in and speak about children because that’s really not where the money is for most dentists. It’s making your whiter and brighter smile so you try and counteract that but we’re, it’s, it’s really difficult. (P10.1 L459)

One participant expressed and summarized concerns about ECC and its impact on child health, which was explanatory enough to provide a very clear image of what ECC does to our

31 children, in the short and long term, and posited that leaving a child with untreated ECC becomes neglect.

... I think about the fact that 28 percent of all children have some form of early childhood caries in North America and that 23 percent of them never get treated so I think a lot of the kids we don’t see and I think of them as having the potential of suffering from the ramifications of not getting treated, which includes malnutrition which includes sleep deprivation, which includes chronic pain, which includes chronic infection and all the things the, that, ah, stem or that follow those particular disorders such as neurologic damage in the development of the child such as potential obesity situations where the kids can’t chose healthy solid foods so they tend to eat softer mushy things and that becomes a learned response neurologically in these children so if they ever do get out of pain, they still neurologically want to eat softer foods ‘cause it’s a learned behaviour. Um, I think of the potential impact it has on the gastrointestinal system. I think these children swallowing all that bacteria and have two months a year; they have an impact on whether these kids develop irritable bowel syndromes or inflammatory bowel syndrome. I think of these environments those kids are living in and it’s because like you know this, this leads, this, ah, ah, caries becomes neglect and becomes abuse if a parent leaves the child in pain for months a year ... (P1 L276)

... I think of the consequences of early childhood caries which the immediate consequence is usually pain and suffering and the ultimate result would often be an operating room experience for a little child. (P9 L117)

Dental hygienists

From the small sample of people with background in Dental hygiene we had gained interesting insights about how passionate they are with respect to child health:

... we’ve all seen early childhood caries and, the concerns that we have about the health risks for these children ... it is something that I think we all as dental hygienists feel very passionate about trying to help to prevent it from getting worse and then when we identify it trying to get that child ... treated as quickly, as possible because we know how traumatic it can be and we also of course as dental professionals know, not just the systemic health risks but we also know of course that it can affect the adult teeth and so, um, we always work to you know to help to, treat it and prevent it, you know but it’s definitely a passion, in most dental hygienists I’m sure.(P8 L289)

Questioning participants about ECC gave us also interesting responses that involved the development of feelings and a moral questioning about ECC. Participants expressed feelings, like anger and frustration when they see children with ECC:

... really anger...’cause the child is innocent right and it’s the parents[responsibility] to be taking care of their children’s teeth.(P7 L148)

But they also expressed ideas that sometimes are shared by the general population and are mixed with stereotypes that surround ECC, by linking the presence of ECC with socioeconomic status and race:

... I know that there’s a lower socio-economic status is one of the clear links with early childhood caries, a higher percentage ... (P8 L662)

... And also certain populations, you know sometimes the Aboriginal community may have more evidence of early childhood caries ... (P8.1 L665)

DV specialists

The knowledge about ECC was limited among interviewees whose background is not in dentistry. From the two experts in DV, one did not know anything about ECC and the other participant let us know that her knowledge of ECC were more related to what she knows as a parent, about caries and teeth care (P6 L284). With these participants, the development of the subsequent questions were more directed to their knowledge of DV, their area of expertise , but trying to obtain some opinions about different topics related to dentistry and DV together.

Summary

During the course of the interviews the views of the participants were expressed clearly with respect to ECC. ECC is seen as a disease that is caused by many factors. Participants expressed opinions based on what they knew about the disease under different points of view: as dentists and dental hygienists; and as parents. Diets, education, socioeconomic factors, among

33 others were mentioned as factors that intervene in the origin and prevalence of the disease. ECC was viewed as a devastating disease for a child, whose consequences were known by many interviewees, as seen in their practice. Dentists and dental hygienists considered ECC a public health problem with high prevalence, and if they have to address ECC it is by the traditional methods: implementing an oral health program that addressed nutrition, education, and regular visits to the dentist for checkups and application of preventive materials. The words “acute and chronic pain” and “malnutrition” were mentioned regularly and gives us an insight into the magnitude of this disease in the minds of our interviewees. The need to prioritize ECC in the agenda of the regulatory bodies, and to give more time to ECC in undergraduate and continuing education programming for dentists was prominent in our interviewees’ comments.

In the next section we will showed the views expressed by our participants about DV, concepts of DV and amount of information provided for undergraduate students about DV, as well as how these health professionals dealt with incidents of DV in their practices.

Framing DV

Dentists

Our participants were asked about DV: what was the first idea that comes to your mind when you think about DV? Some thoughts shared by participants included stereotyped ideas about DV seen as violence against women and perpetrated by men (P4 L67; P5 L59). We also obtained other responses:

When I first thought of domestic violence, it was related to what I had seen in the office where the husbands were verbally abusive to the wife and leading to physical abuse ... I saw that so it was a combination of verbal and potential physical abuse (P1 L206)

I think of ... power differential between two people; and domestic violence can happen against a man or a woman and ...either a heterosexual relationship or a same sex relationship ... so I guess I think of it really broadly ...that it [DV] stems all sort of socio-economic and cultural strata, that it’s not confined to certain groups of people. It can happen in any type of social relationship type setting. (P2 L77)

... when I think about domestic violence I would think generally it would be about, the first thing that comes to mind would be abuse, and this would be, could be either spousal abuse or child abuse, and I would think of it, not only in terms of physical abuse but of course this could also be other types of abuse, mental abuse or psychological abuse. (P9 L81)

Participants considered that they have a role to play in DV interventions. We gave them a set of alternatives that included: awareness; reporting; and follow up. Participants were encouraged to elaborate on each of the alternatives.

... I think that, well, we have a legal obligation to report families who refuse to treat early childhood caries. Part of that, when you’re reporting that, inadvertently I think you end up reporting the potential of domestic violence based on my experience to date. I certainly think we have an obligation to protect the child that we see and to protect the women who are victims (P1 L 224)

... certainly in awareness; not in reporting. I guess it depends where you live. It’s not a reportable thing in Ontario. Child abuse is but domestic abuse is no, so I don’t think there is a role for reporting. There’s a role for awareness and, you know for, um, perhaps counselling. (P2 L99)

If the issue becomes apparent in a dental office, then the staff should be able to have the knowledge to know where to refer these people and, I think that’s the awareness and referral part; it is part of our obligation (P4 L94)

Participants were questioned about incidents in their practice, now or in the past, if they suspected DV in their client populations, if these incidents involved children with ECC and if they felt comfortable dealing with these incidents. Interestingly, five out of eight participants with background in dentistry had incidents of DV or suspect DV in their client populations, five of those experiences involved children, four of them regarding ECC.

During the interviews, several reasons were mentioned for avoiding the process of reporting DV cases: risk of lawsuit; professionals more concerned about their business; lack of training; DV considered an unpleasant subject to talk about; and one participant suspected that a dysfunction within the dental professional’s (dentists/dental hygienist) own family context could be one of the factors that make it difficult for professionals to get involved in reporting DV cases;

... dental professionals are not trained to deal with these situations and so they’re very reluctant to get involved (P4 L83)

I think we, as a professionals tend not to want to get involved because people are more concerned about the business in their office than necessarily what goes on outside their office and their concern about the potential of making an accusation and having a lawsuit come back at them (P1 L255)

One of the participants felt that his patients would not be willing to trust information about DV from him, because he was a man. Other participants proposed that a dentist was not the type of practitioner that people living with DV were going to trust when they were ready to disclose the DV.

About undergraduate preparation and curricula, only two lectures in DV were identified at the university level, one of them being an introduction. Dentists considered that the amount of information about abuse, violence and how to handle it was insufficient. Participants involved in educational roles in dentistry reported that they did not think that two lectures were going to make any difference once the student graduated and faced a case of DV/child abuse in their own practice. They also doubted that signs of DV could be recognized. They did not think that a student would remember or act unless they received more information or more specific training.

As a result, students’ preparedness to recognize report and handle appropriately DV incidents in their future practice was in doubt.

DV was not mentioned in either of the annual reports of the ADA. An NVivo™ text

search of the documents showed no indication that DV was on the agenda for those meetings, no

continuing education courses covered the topic, and it was not mentioned elsewhere. We

conducted an NVivo7™ text search for ECC in the AGM reports (only 2 available), code of

ethics, and position papers. For dentists there was one article in the code of ethics that referred to

reporting child abuse.

Dental hygienists

First ideas from these interviewees are not very different from the ones expressed by the group of dentists; they add violence against elderly people into the definition of DV (P7 L108)

and also the notion that DV is an uncomfortable topic to talk about:

I think that the first thing is that it’s a hidden topic that people don’t want to talk about very much. That’s you know just the first thing that comes to my mind and then just consider all the various aspects of, of abuse could be physical, mental, verbal, economic. It’s, that, those are the first things that come to my mind. (P8.1 L122)

... the first thing of course when I think of domestic violence, um, in terms of who it would involve, typically I would think like I, you know a husband and wife, um, type of thing and then of course if the children are involved as well so that’s sort of, to me when I think of it those are the people that I think, um, that would be involved in you know first comes to my mind (P8 L132)

Dental hygienists consider themselves in a special position to recognize physical signs of

DV because they perform their work very close to their patients, which makes them able to spot

signs of violence. Dental hygienists perform extraoral exams, which put them in the position of

more closely examining the upper body. They were however careful not to make generalizations

about dentists and dental hygienists with regards to this topic. Roles of awareness, reporting and

potential follow up were mentioned from participants of this group.

... we certainly do feel that dental hygienists, or dental professionals in general, because we can either work one or one or the mom is in the room with the children, I think that we’ve often, we’ve really felt, that they do have a role and they may be in a unique position even more than the physician often because we do spend a very, a concentrated time, to identify ... some things that may not be readily noticeable in that five minute interaction, by maybe other health professionals. (P8 L174)

You may have a chance to develop more of a relationship with people just because of the length of time that we’ve spent with them and just the comfort that they may have with the dental hygienist (P8.1 L188)

... because we’re doing the extra oral exam so we’re feeling around the neck, the back of the neck ... Sometimes now that there’s more women coming in with the scarf around their neck, then sometimes it’s harder because you can’t see then right. It’s all hidden underneath the shawl ... (P7 L390)

From the group of participants with background in dental hygiene, only one of them had

some anecdotal experience about incidents of DV. There was a suspicion of abuse in the mind of

the participant, but when asked about what action was taken the answer was that even though

there was some suspicion about the case, and the answers to her questions raised more suspicion,

the participant did not report. In a different case the same participant acted differently:

... In my own private practice experience, I’ve had two incidences where we have suspected, where we’ve been you know verbally quite guess angry is a word where we have really talked to the parent or whoever brought in the child that it was their responsibility to make sure their children were taking care of their teeth ... In the one case, we actually talked to the parent that if we did not see a change in pattern in the next two weeks that we would call Social Services ... and so she came back in two weeks and it was much better. The plaque control was better, so I mean I don’t know how, how long it’s going to be better (P7 L156)

Other participants did not have any experience dealing with DV, or suspected DV when

practising as dental hygienists; however one of them gave us an example of what approach they would take if they suspect DV in their client populations.

... For example if, if a, a mom brings the child in, or the community health dental hygienist is talking with her, a parent with a, with a woman and has a suspicion of abuse, then she can ask some probing questions... sort of part of the

relationship building, are you, are you in a safe environment? and if the woman says well you know and shares part of her story, then the dental hygienist in that setting may be working in an office where the social worker [works] ... so she’ll, rather than, than saying well that’s too bad, then she can say we’ve got some people here who may be able to help you. Do you want me to? Do you want that assistance? ; And the person will say yes I’m desperate and so then they can take them right down to the social worker and facilitate things. However it needs to be from there whereas in a dental office, a dental hygienist really is pretty remote from some of those services. she may know about them and be able to provide a card to the individual, you know referring it to some social services agency but there’s that disconnect there and so it’s a different practice setting for dental hygienists are working in as well.(P8.1 L252)

When questioned about the proper method of questioning a patient about DV, our participants mentioned lack of training and feelings of uncertainty. Their focus was on getting the “truth”, that is, how they would know if the patient, whom they suspected was in a DV situation, would be telling them the truth or not.

... but you know we still kept questioning them to make sure that was really the reason, that it wasn’t something else...but you would never tell, like exactly, exactly if it is the truth or not ... especially in cases of domestic violence (P7 L277)

Dental hygienists had a lecture on violence, specifically, violence against females, child and elder abuse. An interviewee whose role is in education considered that with the help of the lecture on violence, and the unique closeness of the dental hygienists with the patient, when they perform the extraoral exam they are more able to recognize physical signs of DV.

DV specialists

A broad answer was obtained from another expert who expressed her concerns about the use of the term domestic violence and the boundaries that come with the use of that term:

One of the things that first comes to my mind is it’s a very loose term, domestic violence. I tend to think of it as intimate partner violence against women, and I know that people define it differently but, I think from my work over the past 25

years, the greatest concern about victims is really women who are abused by intimate partners, physically, emotionally, sexually.(P6 L81)

... even for women victims, when is it abuse, when is it marital conflict, you know we don’t, we don’t sort of have a dividing line there. I think we, we have done such a good job in alerting the police, the justice system, the health system to identifying domestic violence but we don’t really give them any sense of when is this abuse likely to be really damaging. I actually think we’ve widened the bound-boundaries a little too much (P6 L 151).

Going further in the interview I asked if she considered that exposure to domestic violence is harmful for children in any way; and she explained that there is controversy about the subject.

I think it’s harmful for about half the children. I, I think, there’s a real debate across North America about whether it should be considered, a form of child abuse ... in probably 70 percent of the cases of domestic violence, children are themselves harmed physically so I think for children who are only exposed, who are not abused by the, the perpetrator that about half of them show some issues and half don’t. My concern is I think there’s other forms of child abuse including physical abuse, neglect, that are not being dealt with because having defined in the Alberta legislation, children exposed to domestic violence has been defined as a, as a form of child abuse and that means that there’s numerous cases coming in that have fully flooded the child welfare system so I have, I have some concerns about it (P6 L98)

About child neglect, her definition was:

... well child neglect is, ah, is when you, ah, deprive a child of the necessities of life and that can be defined pretty broadly but often includes food, shelter. Ah, certainly, um, we see as one of the issues that if you don’t provide them a safe environment to live in, it’s, that it would, it would fall under the blanket of child neglect. (P6 L168)

Even though the participant has a background in social work, when we asked about DV as a public health problem, if she sees DV as a public health problem; her answer was:

... health is not my background. I’m a social worker so I see it as a social problem so I guess it’s a public health problem to the extent that in many cases the health

system is involved in addressing the issues. I guess I would have to say yes. (P6 L236)

When asked about the role that dentists and dental hygienists should play in DV interventions, the answer involved some hesitation and questioning the fact that perhaps these types of professionals are not the ideal professional to play a role in DV.

I think the role that they had, if they made us, children are showing up in their office with lots of cavities, that’s not normal so understanding that it might be a risk factor knowing that, um, babies are being put to bed with one of the milk or pop or sugary foods, um, might be, what I understand is the parents might be utilizing that to keep their kids quiet so that the partners don’t get aggravated and commit domestic violence so yeah I think, um, if the child is showing up with lots of cavities, it’s an indicator of many things. It could be violence in the home, it could be poverty issues where the kids are eating too much processed food and people don’t understand about dietary, dietary guidelines. I think kids showing up with lots of cavities, not all ‘cause I understand it could be hereditary as well but that it, it should be a flag for the dentists and the hygienists. (P3 L165)

... dentists are not counsellors so, again I have a little bit of concern about, you know they are professionals but when you start even how to raise the question, is it some form of child abuse, do they know the resources. I mean I think there’s all sorts of potential problems if we start, if the protocols would have to be very well done and I would be very concerned that they’ve got really good training and they’re not asking questions in ways that don’t scare the client is a really difficult thing to do. I just, I mean they are not that kind of professional ... I think that the major role of dentists with domestic violence may well be with adult women and noticing damage and broken teeth ... (P6 L385)

Summary

Some participants considered that dentists and dental hygienists are more able to recognize physical signs of DV because they perform their work very close to the patients, which make them able to spot signs of violence such as bruises. Dental hygienists perform extraoral exams, which put them in the position of more closely examining the upper body. On the contrary, when a professional from a non-health discipline was consulted, the response was that dentists should not be considered as counsellors.

Dentists and dental hygienists are encouraged to contact their regulatory body if they have doubts about procedures to follow in DV cases. When we asked people from their regulatory bodies, they redirected us to other resources such as a webpage from the Government of Alberta. This resource is readily accessible. Questioned directly, representatives from the regulatory bodies offered no protocol in place for DV cases. Dental hygienists have information about violence on their webpage. CRDHA provides their members with newsletter articles, online courses and some webinars to educate their members about DV; these courses, however, are mostly oriented to elder abuse.

Participants mentioned the need for continuing education courses in domestic violence and abuse to be added to the agenda of the courses offered by the regulatory bodies.

Ideas about violence from participants with background in dental hygiene include the notion of violence against children, and elderly people; but also the ideas that violence is an uncomfortable topic o talk about, and as they expressed themselves, a “hidden topic”. The concept of DV was differentiated from the concept of child abuse as if they were inherently separate concepts. Their idea of reporting is strictly related to child abuse, not DV. Although dental hygienists regulatory bodies have more information available in case of reporting child and elder abuse, it is still not enough to address the need for information. There is one article in the code of Ethics about reporting client abuse, in the CRDHA. Participants with Dental Hygiene background were more open to explore the role that they can play in DV interventions. Their responses were based on what they think they will do in case something like DV happen in their practices. From all the dental hygienists in our study only one suspected abuse and reported it, and although all of them said they are ready to report if they suspect DV, the majority of them

never suspected DV in their clients. DV specialists’ views of dental practitioners with respect

with DV interventions are non-inclusive, leaving them outside the umbrella of participation.

In the next section we will report the responses of participants about the intersection of

ECC and DV. If they considered a possible link between them and also if this link could be considered urgent to address by the dental community.

Intersecting ECC/DV

Our results showed that even though DV and ECC are considered highly prevalent issues, they are viewed separately. Although participants did not find a linkage between ECC and DV and saw no urgency for action, they were aware that there is the possibility of a linkage. Two questions in our interview had the objective of addressing the possible linkage between DV and

ECC: a) Based on your experience or what you have heard from others in the field, have you had any reason to think that there might be a link between ECC and DV in some cases?; and b) Do you have any concerns that ECC and DV are linked? Four participants considered that there was not any link between ECC and DV. Three participants responded that a link between them was absolutely possible, though some of them reflected that only in some cases could ECC and DV be linked. They mentioned that there are many other factors, indicators and signs to look for, and to be considered as a whole when an ECC case was assessed.

Dentists

Participants with background in dentistry shared interesting points of view, using the

term “common sense” to explain some observed behaviours of parents with respect to the health

of their children

... again I don’t know if each and every child has early childhood caries comes from an environment, a dysfunctional family but if a parent is refusing treatment, I think that is a dysfunctional family (P1 L452).

When asking Do you have any concerns that early childhood caries and domestic violence are linked? Participants responded:

Well I think early childhood caries is a marker of domestic violence ... untreated early childhood caries. I think is a bigger marker of it. You know some, some parents just don’t know and before they know it, the child has early childhood caries but they usually seek attention right away and treatment so with that group I’m not as concerned about, as I am about those who are untreated (P1 L489).

... is that there seems like there, there is a link that’s present, and my biggest concern is I don’t know how we would go about teaching, or improving that situation.(P5 L105)

I would be surprised to hear... I have never looked at it or researched it or questioned it; but I would be surprised if there’s a strong link. You know I think to a large extent, early childhood caries is grounded in poverty ...or poor, not poverty, but lack of access to resources whereas I don’t think that about domestic violence. I think it can happen in any setting. I think it can happen you know in, in all settings. I don’t think it’s necessarily linked you know to poverty or to that or those kinds of things. I mean in some cases obviously it is, but I don’t think on the whole that it is and obviously we see, I don’t see ‘cause I don’t treat kids but I know my colleagues see early childhood caries in across the sphere you know, kids from well to do families but I think to a large extent, it’s a problem of disadvantaged people. (P2 L164)

The same participant showed some discomfort with the possibility of linking DV and

ECC and probably this was the first time that the linkage between them was presented to her.

Well I’d be surprised. I mean you know you never know. I guess you know that’s what you’re maybe researching in some way but I, I had never thought of the two together. (P2 L245).

The link between ECC and DV is mentioned, but it is also disparaged by the concern that inadequate scientific evidence is available to establish a credible link, or dismissed by comparing it to a silly situation.

I think a lot of people may feel that there certainly could be a link. For example you have a little child with pain, then you can certainly anticipate that a parent who gets very upset or frustrated may actually get into an upset mental state and consequently you may see domestic violence or child abuse erupting in terms of for example shaking a baby or hurting a baby to see if you can get them threaten them and obviously it’s not anything you would want to see happen but, my belief is that there certainly could be a linkage. I have yet to see scientific information showing that there is a linkage. (P9 L157)

... there’s so many different things to domestic violence. Domestic violence could also be dental abuse. We probably see that more than, than we do physical violence, a child not cooperating, their child being withdrawn, things like that. If you looked into see what a dental care issue was, a mother wants to stop her kid from crying so she gives him a bottle so it, it gets a lot of caries and do you say that’s domestic violence? I don’t think that’s domestic violence. She’s got other problems besides the child crying so she tries to compensate by giving a bottle that, isn’t going to really solve the problem long term ... if you look into a mouth and, and you see, you look at caries and say okay I’ve got [inaudible] some violence here, I don’t, it, it might be a factor but it, but there, there’s a lot of other factors that you would have to look at (P 10.1 L316)

Well if they, you know go into the dental office and the dentist told the parents that their kid has twenty cavities and the parents started arguing that [inaudible] if I was accused of ... or every time my wife and me argued about something about it, it means that we have domestic violence in our home, you know, that’s a really stretch. (P10.1L335)

When we asked participants about the urgency of dental health professionals to act on the link of ECC and DV, their answers were:

I don’t think it’s an urgent ... thing. I think it could be an interesting research question and if there did prove to be a link, I don’t know that it would you know affect the way that those two problems should be dealt with. (P2 L256)

Sometimes, participant answers gave the impression that they are not involved or that distance has to be kept between them and a possible situation of DV, and that DV and its relation to ECC is an individual or isolated problem

So if, if there is a family in this situation, there’s no question that it would be very urgent for that family to have some help in this, and so on an individual basis, I would say there’s no question that it would be urgent of course for any family in this situation but then if I take the broader view and, and look at this

from a public health program, so I’m not speaking to you as a private practice dentist anymore seeing patients in my office every day... and now we’re looking at people who aren’t getting good access to oral health care and falling through the cracks, I think there’s more urgency and we can impact a greater number of people if in public health where we’re doing what we can for the, for the greater number of people who are affected by dental caries and I think that’s the approach we’re taking (P4 L243)

Dental hygienists

Participants who were speaking from the dental hygienist point of view rationalized the

idea that there are other factors involved when they come across a non-treated ECC case.

Regarding DV, they were in uncomfortable territory

I think dental hygienists, you know we said we have to look at it as an overall, like the person overall and not just get narrowly focused on this person has cavities and we want to solve that problem but how can we, I mean it’s their, you know they’re giving, the Mom is giving them that because they want them to be quiet so they don’t get beaten, you know that’s a bigger problem and, we can’t just solve it by saying, you know, doing our traditional dental treatment (P8 L597)

Then participants slipped in the idea that DV could be involved, but they are reluctant to say that there is a clear link between DV and ECC. One participant remarked:

We don’t, I don’t, I don’t know. I haven’t researched it deeply to know all of the evidence that be available. You probably know more about that than I do but, but there, you know it just seems that perhaps there could be somewhere but I would hate to assume that every child that comes in with early childhood caries, that you would think oh this must be a case of domestic violence because, I mean don’t think that connection, I don’t think you can make that connection that way. There may be, it may be a, marker for that you might want to investigate but, you know the same if the child comes in with lots of bruises, you know do you think oh dear, dear this is physical abuse whereas it’s really is just a clumsy child who is very, very active ... (P8.1 L 618)

... there isn’t a lot of clear linkages and, there’s always exceptions to everything, maybe you know is it early childhood caries? Is the link with domestic violence or is it the lack of getting the treatment for somebody with early childhood caries is more of a clear link? You know it’s, it’s just so hard to know, but certainly I

know that there’s a lower socio-economic status is one of the clear links with early childhood caries ... a higher percentage. (P8 L654)

The link between ECC and DV is not made in the mind of most of participants; there is a broken relationship between what participants considered their scope and what domestic violence prevention activities will demand from them , they understand that their traditional approach is not going to be sufficient enough to address domestic violence prevention.

DV specialists

We wanted to know what ideas about the intersection of ECC and DV are shared by our experts in DV. We chose one excerpt that summarize the DV experts opinion about the intersection of ECC/DV

... one of the key issues is a real overlap in, in, in poverty, issues and, and depending how you kind of formulate and do different things ... I think poverty, lack of education, lack of good role models which could come from a variety of things including having been abused as a child yourself and, and perhaps exposure to domestic violence, but I would think that if you, if you’re a dentist and you have a child in your office where you’ve got a lot of concerns about health care, it might be domestic violence but that wouldn’t be the first thing I would look for. I would look for parental knowledge about, things like you know like the baby bottles and, I’d look for issues of, can the family afford issues. It just would not be the first thing that I would look at. (P6 L314)

The views of our DV experts about the intersection of ECC and DV showed us that they do not discard the possibility of a link; however, they will go for other factors that could affect the presence of caries. DV will not be their first option.

Summary

Our results showed that dentists and dental hygienists that participated in the study are somewhat aware that there could be a link between ECC and DV, but they are not comfortable accepting that possibility. ECC linked to DV is in the mind of most of our interviewees a remote possibility and the need for more research is mentioned frequently. As a consequence the

47 urgency for acting on the link between ECC and DV is nonexistent for most of them. Participants distanced themselves from the problem of DV; and blamed other factors acting in the development of ECC.

Chapter 4: Discussion

The data were analyzed for patterns in how ECC was framed by participants, how DV was framed, and how the intersection was framed. In so doing several patterns emerged in terms of confirmation of the literature on ECC, and two patterns with respect to DV and the intersection of DV and ECC: gaps and opportunities. In this chapter we will discuss the value of using a qualitative research design, the results of the analysis, and the strengths and limitations of the research.

A qualitative research design was chosen based on the nature of the questions that were formulated: How is the intersection of early childhood caries (ECC) and domestic violence (DV) framed by dentists, dental hygienists, their regulatory bodies, oral health professional leaders and domestic violence experts in Alberta?; and what regulations, policies, and protocols are in place in Alberta to guide dentists and dental hygienists when ECC intersects with DV in their client populations? As Morse and Richards explain: “we see qualitative research as a wide range of ways to explore and understand data that would be wasted and their meaning lost if they were pre-emptively reduced to numbers” (Morse & Richards, 2002, p. 2). A qualitative design was the appropriate choice since many relevant observations were made based on what the participants agreed to share openly with us, and that enriched this study.

Framing ECC

The first thing we noted as we analyzed the results was that the participants’ descriptions and discussion of ECC were consistent with the literature. As expected, similar definitions for

ECC were referenced by the participants. Participants agreed that ECC is a disease that affects children’s teeth, and that it is a complex disease with many intervening factors. (See Chapter 1 for a more complete description). While both dentists and dental hygienists have similar

impressions about what ECC means, its burdens and treatment, they acknowledge that there is

much more to be done to prevent ECC and promote children’s oral health. These professionals treat children with ECC; they do not want to start thinking that every child with ECC could possibly come from an environment where DV is present. We disagree with that approach. If there is a possibility that a child who comes to a practice to be treated for ECC, then oral health professionals need to do a comprehensive diagnostic assessment by addressing not only commonly known etiologic factors for ECC, such as education, hygiene and diet, but other factors as well (e.g., the social determinants of health) such as stressors at home. Dentists and dental hygienists are protocol-oriented from a disease point of view; they do not take a perspective of the child in the social and cultural contexts of his/her life. That means that oral health practitioners need that broader perspective or orientation if they are going to address social issues affecting a child and family. They must view the child as an individual who belongs to a family, and is part of society; they must go beyond seeing a child in isolation.

In this regard, there is an opportunity for oral health practitioners to embrace a family-

centred approach to their practice. Family-centred care emerged as an important concept in health care at the end of the 20th century and was promoted most prominently in the context of child health. It reflects a shift from the biomedical aspects of health services to a more inclusive view that respects the family as an integral part of the health care team and accepts the importance of meeting not only the medical needs but also the psychosocial needs of a patient. It is a more holistic approach to care. Research into this model of care shows that a family-centred approach leads generally to greater compliance with treatments, more prudent use of resources, improved satisfaction with quality of care, greater morale among providers, and a greater sense of accomplishment (Potter, Perry, Wood & Ross-Kerr, 2010).

Framing DV and the intersection of DV and ECC

It is clear, theoretically, that ECC and DV intersect; both are widespread phenomena in our society; both are preventable, multi-factorial and affect children’s well being. DV, like ECC, can happen anywhere, in any social class; it is not only a woman or a minority problem

(Anderson & Aviles, 2006). Both DV and ECC can lead to future health problems - parental violence can lead to behavioural problems with emotional and physical manifestations during adolescence (Ireland & Smith, 2009); and ECC can affect children’s nutrition, their ability to chew normally, in turn affecting growth and development.

Key results

The results obtained from this study helped us to identify five gaps in the understanding the intersection of DV and ECC. We identified gaps in practice, knowledge, education, research and in intersectoral and interdisciplinary action.

Gap in practice

The intersection of DV and ECC is not a new subject but there continues to be resistance to making this link relevant to practice; as it can be noted by the content of the interviews. The intersection of ECC and DV was the object of exploration some years ago, with the work of

Blumberg and Kunken (1981) who suggested that the presence of untreated tooth decay “... may be first sign of child abuse and neglect” (Blumberg & Kunken, 1981). They also mentioned how

DV could be playing a role in the development and permanence of ECC, by presenting a case of a child with ECC and the use of bottle feeding to sleep as a way to soothe the baby, avoiding crying and further beating from the abuser (Blumberg & Kunken, 1981). Rupp (1998) expressed that dental neglect, specifically addressing untreated oral conditions, could lead one to suspect child maltreatment (Rupp, 1998). Other studies done in the same decade suggested that abused or

51 neglected children have more need for dental intervention than children with no history of abuse or neglect (Greene & Chisick, 1995). More recent studies suggest that abused and neglected children have more tooth decay compared to children from the general population (Valencia-

Rojas, 2006; Valencia-Rojas et al., 2008; Montecchi et al., 2009). Although anecdotal evidence was provided by a pediatric dentist working in Calgary who witnessed an episode of family violence in his office that involved children with ECC (Cole, 2008), little evidence exists in the literature that demonstrates ongoing research on this topic in the past two decades.

The focus of this study was to understand if and how dentists and dental hygienists framed the intersection between ECC and DV. We have come to understand that they are, for the most part, framed separately and considered not to be related. However, dentists and dental hygienists also comprehend the responsibility that they have to report and somewhat understand that they have a role to play in DV intervention. But, they do not know exactly how this can be translated into their daily practice. We propose that as a part of a comprehensive approach to the treatment of ECC, dentists and dental hygienists should add a component that assesses stressors in the family that could be affecting parental practices and the oral health of the child. For example, what is going on at home that baby is going to bed with a sugary bottle?

Thinking upstream, there are many possible reasons why a parent could put a baby to sleep with a sugary bottle. Maybe the parents are not aware that doing so could produce cavities in the teeth; maybe they are tired at the end of the day and it is easy to soothe the baby to sleep with a bottle so they can attend to other family responsibilities. When all the other factors that can cause ECC have been sorted out, simple questions could lead to the discovery of other social, psychological, emotional or cultural factors that are missing in the traditional clinical ECC diagnostic equation. If lack of knowledge is at issue, information and resources can be provided.

If an assessment of family stressors leads to the suspicion that DV may be an issue, then dentists

and dental hygienists could provide some information about family service resources, suggest a

telephone help-line, or give a card with information on how to get help. Oral health professional

could create a safe environment for patients to disclose issues of DV (Littel, 2004), but without

further preparation are not the appropriate resource for helping clients deal with it. They must

report (if appropriate) or refer to other services for intervention.

Professional scopes of practice already for dentists and dental hygienists state that they

have a role to play in prevention (Health Professions Act, 2000, p.139); and improvement of

“physical, psychological and social health” (Health Professions Act, 2000. p. 152). Dentists and

dental hygienists help with the improvement of physical appearance and physiological function,

by performing procedures determined by their scope of practice. They also help with the

psychological component of every treatment that aims to improve appearance in the individual.

We were struck, however, to learn that dentist have a social health component as part of their

scope of practice (Health Professions Act, 2000, p.152) and that dental hygienists promote wellness and act as health promoters as part of their scope of practice (Health Professions Act,

2000, p. 139). Our first thought was that the achievement of social health could be done in part

by improving the oral health of the individuals, and we believe that is the purpose of these

statutes. It was not clear if DV could be part of the “promoting wellness” mandate. Improving the social health of individuals could also be accomplished by preventing DV in the general population. By learning about DV and its signs, and spotting those signs their client populations, reporting suspicions about DV (or actual evidence), as well as providing information about available resources, dentists and dental hygienists could then fulfill all aspects of their practice with regard to the achievement of well-being. As Littel (2004) pointed out when discussed the

training for how to identify and report cases of abuse “the training information about

interventions and referrals for patients, left dental personnel perceiving these actions as an

extension of their practice”(Littel, 2004.p. 6). The position statement about personal data protection is important because it states that patient documents that are in dentists’ possession could be released if the law requires it (CDA, 2007). As a result, there is a concordance between

what the law expects from oral health professional and the actions they must take in order to

comply with the law. The position statement about traumatic injuries (CDA, 2005) suggests that

the most important etiology factor is for a traumatic injury as the result of sports activities,

leaving assessment for DV out of the mix.

The professions’ codes of ethics demand that dentists and dental hygienists embrace a new role in violence prevention. Codes of ethics from national organizations such as CDA and

CDHA provide general guidance about issues related to the practice of dentistry and dental

hygiene. However, when these codes are adopted by provincial organizations they develop more

specific guidelines. It is particularly interesting to note that a position against violence is part of

both codes of ethics from Alberta, when they refer to child abuse or client abuse (ADA+C,

2007). Codes of ethics from the local governing bodies for dentists and dental hygienists,

emphasize the need for reporting abuse whenever is suspected (ADA+C, 2007; CRDHA, 2007).

Regulatory bodies assist their members if they have questions about DV and direct them to

resources from the Government of Alberta. Alberta legislation requires reporting of suspected

child abuse to the authorities and it is an expectation for health professionals, including dentists

and dental hygienists to report abuse (Government of Alberta, 2005; Government of Alberta,

2008). Dentists and dental hygienists are responsible for reporting any suspected case of child

abuse. So the expectation and ethical considerations for dentists and dental hygienists with

regards to domestic violence prevention are given, the action to take for violence prevention

could become an issue of individual interpretation.

Participants are aware that there is legislation that protects children and families living in

a DV situation; however, they do not understand entirely Alberta legislation. Exposures to DV

and child abuse overlap (Herrenkohl, Sousa, Tajima, Herrenkohl, & Moylan, 2008). Neglect is

defined as caregiver failure to provide basic care; what is important to note here is that non

treated dental decay is considered as neglect (Government of Alberta, 2012); and neglect most

often does not happen in isolation; it goes together with other types of maltreatment (Mennen,

Kim, Sang, & Trickett, 2010). The Child Youth and Family Enhancement Act (2004) is a strong

piece of legislation that protects children from DV and neglect. If they never suspect DV in their

client population, that probably means that they will have to start looking for signs of abuse, if

you do not look for signs of DV, the chances of finding some indication that lead you to suspect

DV will be minimal.

Dentists and dental hygienists have the clinical skills to identify signs of abuse. We agree with the position Lincoln and Lincoln (2010) expressed about the role of the dentist in the investigation of domestic violence, where recognizing traumatic injuries such as fractured teeth, lacerations, fraenulum tears among others, could signify signs of abuse (Lincoln & Lincoln,

2010); if there is a traumatic injury to the face, and if the practice of a sport is ruled out, the

suspicion of other factors involved should be justified. Literature is also available about signs of

abuse that can be easily spotted by oral health practitioners (Cairns, Mok, & Welbury, 2005;

Gwinn, McClane, Shanel-Hogan, & Strack, 2004). Recognising the presence of the skill set, and

the role of hygienists in extraoral assessments, the questions arises: why is there a gap in

reporting suspicious cases?

Risk assessments for ECC do not take into consideration DV in the household, which

given its prevalence, is a serious oversight. The position statement with respect to ECC

encompasses much information about ECC, its etiology and subsequent effects, but there is no comprehensive approach regarding how to deal with ECC under different situations (CDA,

2010). The management approach to ECC is traditional clinical practice, increasing dental visits, counselling, and the like. The literature suggests an approach that could be used for risk assessments conducted with SDOH in mind in order to decrease the incidence of ECC by using or adapting models developed with the purpose of helping physicians to deal with DV in their practices, (i.e., Asking Validating Documenting and Referring [AVDR] model ) (Gerbert et al.,

2000). These risk assessments would allow a more family-centred approach to oral health care.

Gap in knowledge

Dental professionals do not want to talk about DV. The lack of participation of dentists and dental hygienists served as invaluable data for this study. What reasons were behind this lack of participation? It could be speculated that practising professionals from dentistry and dental hygiene, do not gain anything from this study. It could be speculated also that they find DV to be an uncomfortable subject, and they simply do not want to talk about it. Perhaps they do not see a connection between ECC and DV, or they simply consider their time too valuable to expend it in an interview about a subject that doesn’t interest them. Dentistry is a stressful profession

(Freeman, Main, & Burke, 1995); dentists being one of the professions with higher suicide rates among other professions (Sancho & Ruiz, 2010). As a profession prone to anxiety and depression (Rada & Johnson-Leong, 2004) DV comes as uncomfortable subject for dentists, and

possibly they did not want to have another issue to deal with that could add stress to their lives.

For dentists and dental hygienists, the idea that the presence of ECC could signify a case of

56 abuse or growing up in an abusive environment, was a difficult subject to address in interviews.

It was easier, however, to talk in third person and explain what they were supposed to do in the event that incidents of DV could happen in their practice. DV as one of the possible factors in the development and subsistence of ECC in children is something that dentists and dental hygienists were not prepared to address in the past (Hendler & Sutherland, 2007; Love et al., 2001;

McDowell, Kassebaum, & Fryer, 1994) and still are not prepared to address now (Hendler &

Sutherland, 2007). This is certainly a topic that could be pursued in future research.

There may be many motives behind the attitudes toward discussing the intersection of

ECC and DV. Some participants mentioned the lack of instruction/education in DV as one of the factors; the same responses were obtained by Love et al. (2001) whom identified lack of training as one of the dentist’s barriers for screening for DV. Perhaps they do not see DV as a problem in their practices based on the assumption that nothing wrong is happening to their patients.

Perhaps the signs of DV are not recognizable to them. But DV exists as a population and public health issue, and needs to be addressed. Neglect was cited as one of the signs of child abuse

(American Academy of Pediatrics Committee on Child Abuse and Neglect, American Academy of Pediatric Dentistry, & American Academy of Pediatric Dentistry Council on Clinical Affairs,

2005) and both dentists and dental hygienists are aware that they have the legal obligation to report child abuse.

Is knowledge the issue? The participants with dental background gave many accurate definitions for DV, leading us to conclude that they know what it is and that it exists. However, their responses to the question about what first comes to mind when they thing of DV, their first ideas rarely included children. Why? Maybe they do not want to think that violence against children can happen to their patients and the topic itself is a very difficult one to address. A study

from Brazil found that even though dentists believe that they can detect child abuse in their

offices, a great majority had never suspected it in their child client populations (Azevedo et al.,

2012). There are many roles that participants acknowledged that they can play in DV

interventions; awareness, reporting, and referral were the most cited. Other studies that investigated low reporting rates by dentists report similar results as ours (McDowell et al., 1994).

There are barriers for reporting, like lack of training about abuse, or embarrassment about asking

questions about abuse (Love et al., 2001). Many authors stressed the importance of reporting and

the fact that while the suspicion of child abuse by dentists is higher, reporting is still low (Bsoul,

Flint, Dove, Senn, & Alder, 2003). Dentists felt less responsible about reporting DV (Hendler &

Sutherland, 2007). Many years have passed since the first studies were done that suggested a

relationship between dental neglect and abuse. Still, many dentists and dental hygienists reject

the idea of a relationship between DV and ECC. Further, there is a disconnection between the

responsibility to report suspicious cases, and actually reporting them. It could be argued that

abuse in their client populations was never suspected; as a result, reporting was not the action to

take. Studies suggested a high prevalence of family violence in Alberta; with the highest rate in

partner violence (Cohen & Maclean, 2004). It could be speculated that cases of abused

children/clients are going undetected .We are not stating that there is no reporting of suspected

cases at all; our concern goes to the fact that all suspicious cases should be reported. In our study,

even though the sample was small, some suspicious cases were not reported. It was not because

oral health practitioners did not want to report them, but because they did not think about that

until later. In this aspect then, there is a gap between knowledge and action that needs to be

filled.

In Alberta, where health promotion activities and initiatives for family violence

prevention are widely recognized, DV seemed not to be on the radar for dental professionals.

Documents gathered for this study demonstrated that there is information available for dentists

and dental hygienists in case they have suspicion of a patient or client being abused. The

legislation available is clear and precise about what to do and there is also the establishment of

sanctions for not reporting child abuse. Information on the internet is also available and specific

for Alberta health professionals, and the responsibility of reporting suspected abuse falls to the

general citizenry as well as to health professionals. Members are encouraged to contact their

regulatory body if they come across a case of abuse or when in doubt, but regulatory bodies

mostly redirect their member to existing resources from the Government of Alberta, hotlines

such as: Alberta Supports Contact Centre; Child Abuse Hotline; Family Violence Info Line; Kids

Help Phone; and web pages such as: www.familyviolence.alberta.ca; among others. Alberta has

a great many programs for preventing family violence and creating awareness; November, for

example, is family violence prevention month and many activities are programmed to raise awareness of the issue of DV and its impact on all Albertans.

It was mentioned by participants in our study that there is a lack of epidemiological data to back up an intersection between ECC and DV. There are studies done in the past that showed a possible intersection between ECC and DV, but judging for the answers of participants, it seemed like studies done until are not seen as serious, because of their non-epidemiological nature. However, there are studies that tried to address other risk factors for the development of

ECC, such as parental depression (Al-Jewair & Leake, 2010). In that study, which was carried out in Canada, it was found that parental depression could also play a role in the development

ECC and it is known that depression is sometimes linked to DV.

There are several excellent resources available for dental health practitioners to consult.

Dissemination of documents such as Family violence: Intervention model for Dental professions

(Littel, 2004); or the family Violence Handbook for the Dental Community (Denham &

Gillespie, 1994), will be useful for oral health practitioners. It is quite remarkable that given the amount of media coverage of DV in Canada, that no one has seen the need to replicate the 1994 handbook over the past 18 years. It is time to update and widely circulate. The material and information about how to report abuse is available, but has to be more ready available for oral health practitioners. Position statements, guidance documents and other advice could be created and disseminated by the bodies that regulate the professions.

Gap in education

There is a need to include material in the undergraduate curricula of the dental professions about DV. Student’s preparedness to recognize, report and handle appropriately DV incidents in their future practice is in doubt. Furthermore, the lack of inclusion in the professional curricula provides implicit justification to ignore the problem. Dentists are aware that they have the legal obligation to report child abuse but the level of preparation or instruction that they have with regards to dealing with DV is minimal. As a result, neither dental nor dental hygiene students are prepared to recognize, report, and handle appropriately DV incidents in their future practices. Our results corroborate the findings of Gutman and Solomon (2002) who conducted a national survey about family violence content in the curricula of dental hygiene schools in the United States and concluded that what is taught is insufficient, and the content of family violence in the curricula needs to be increased in order to improve awareness and reporting rates (Gutmann & Solomon, 2002) As another author suggests, training increases the self-perceived likelihood to report abuse (Harmer-Beem, 2005).

If faculty in dental and dental hygiene programs feel unprepared to teach about DV, then

innovative methods should be considered to present the topic to their students. They might

consider including professors from other faculties (e.g., nursing, social work) and using new

technologies to bring in the perspectives of DV experts, people who have experienced abuse,

community police, and others through such means as video conferencing. Similar methods could

be used to address the requests from participants for more continuing professional education.

Oral health practitioners need more from their regulatory bodies. Questioned directly, regulatory

bodies offered no protocol in place for DV cases. Introducing more comprehensive instruction

with material available about DV and the efforts that can be made by health teams will increase

the likelihood of reporting.

Gap in research interest

Since dental practitioners are seen as key players in ECC and DV prevention, regulatory

bodies should encourage participation in research that addresses the intersection of these two

issues. Participants noted the lack of research in the area to favor the hypothesis that ECC and

DV intersect at any point. However, studies with respect to this subject have been done, then we

could speculate that it is not lack of research done, but lack of dissemination of results combined

with lack of interest about social issues from dentists, dental hygienists, their regulatory bodies

and society in general, which do not see a role for oral health professionals in DV prevention,

and comply with the apathy of the dental community to participate in DV prevention issues. The research interest in dentistry and dental hygiene probably shifted to another object, more

interesting than DV, a “hidden topic” for the dental community. And that is one of the possible

reasons why there is a gap of many years between the first studies that acknowledge that

something was going on between ECC and some parental behaviours that could be the masking a

“living with DV” situation

Gap in intersectoral and interdisciplinary action

The need for collaboration and interdisciplinary practice was an important finding in this

study. The lack of similar messages from all health practitioners (i.e., physicians, paediatricians,

nurse practitioners, public health nurses, dentists, and dental hygienists) results in confusion for

parents and caregivers with respect to the prevention of ECC. Successful preventive strategies

depend upon consistent advice from health practitioners that work with children (Gussy, Waters,

Walsh, & Kilpatrick, 2006). ECC needs to be addressed in coordination with other professionals,

and successful interventions for ECC must occur early in childhood (Gussy et al., 2006). Oral

health practitioners must work in coordination with other health professionals, family physicians,

pediatricians, public health nurses, and social workers and be part of a multidisciplinary team

effort if the incidence of ECC is to be reduced and children’s oral health is to be promoted.

It was discouraging to listen to some points of view of people working in DV, suggesting perhaps that dental professionals have no role to play in social issues or health promotion. This is an important finding as other health professionals are certainly viewed as having a role in preventing and treating DV. It represents society’s view of the limited role of dentists and dental hygienists in health promotion. We need to welcome dentist and dental hygienist to the field, and they can fulfil their roles as expected in their scopes of practice.

Given the number of gaps that were identified, it is incumbent upon us to present some solutions in terms of opportunities for action that were identified by participants, in the literature and from the analysis.

Opportunities for action

We encourage a conjoint action from dentists, dental hygienists, educators, leaders, DV specialists and other members of society, to fill the gaps identified by this study and improve how the intersection of ECC and DV is addressed.

Opportunities for practice

Based on what we heard on the interviews and learned from the documents we analyzed in this study, we have one recommendation for practice. Given that dentists and dental hygienists recognized that they have a preventive role to play in DV interventions, this role must be embraced and internalized, and their considerable diagnostic skills should be used more effectively in a family-centred context to perform ECC risk assessments with the social determinants of health in mind.

Opportunities to fill the knowledge gap

This study identified a gap in knowledge and action, between what dentists and dental hygienists know about their obligation to report abuse, DV, neglect, and the action that they take.

We recommend that regulatory bodies should put more emphasis in promoting what Alberta legislation requires from dentists and dental hygienists, helping them doing the transition to their practices, this could be achieved by the development of workshops for this purpose as well we recommend that regulatory bodies should participate more actively in coordination with other organizations in Alberta, promoting activities for family violence prevention.

Opportunities in education

Based on all the views expressed in this study, along with what literature suggests, we recommend increasing the amount of time devoted to the social determinants of health and the

63 dental role in DV prevention in undergraduate education. We also recommend considering innovations in pedagogy and instructional design to bring DV prevention information to undergraduate students and to continuing professional education activities.

Opportunities for future research

There are two main suggestions for research. The first one is to develop a preliminary incidence study; that will look for DV incidence in children with ECC. This future study will contribute with a line of research that is still not fully investigated. The second suggestion for research is to develop a participatory research project for dentists and dental hygienists associations, focused on the issue of DV.

Opportunities for intersectoral and interdisciplinary action

Based on the points of views expressed during this study by all key players, about the need of a integrated and multidisciplinary response to DV; we recommend to welcome dentists and dental hygienists in activities for DV prevention; and include them in conjoint activities with other professional that are working in violence prevention, and we recommend for this purpose to look for a more participatory approach from the regulatory bodies in promoting the role of dentist and dental hygienists as team members in DV prevention.

Significance of the study

Research in this area is important because it will create awareness about the intersection of ECC and DV. This study presented an exceptional opportunity to initiate discourse about two population and public health problems, ECC and DV, separately and together. The greatest contribution of this study will be in setting the stage for a larger program of research. This study identified gaps in practice, knowledge, education, research interest and intersectoral

64 interdisciplinary action. To be successful, those gaps will need to be addressed with an intersectoral and interdisciplinary approach. This study also identified the need of other key players in DV prevention, and society in general, to have a more open mind and embrace change in order to integrate dental professionals into their DV prevention strategy planning.

Strengths and limitations

The qualitative method chosen was one of the strengths of this research. The use of the semi-structured interviews allowed us to generate rich data that proved to be valuable in the process of answering our research questions.

In terms of access to leaders in the professions, we were fortunate that there was a high level of interest and participation. It may be that this is where the action will come from once the results of this study are disseminated. We were not able to recruit dental hygienists in independent practice to participate. Perhaps had we worked more closely with the College to gain their support; they might have encouraged dental hygienists who are employed within a dental practice to participate in the research.

There were some difficulties in access to certain documents. We were expecting to obtain and analyze key policy documents from national professional associations but we were unable to do that, creating a limitation to the study.

The preconceived notion about ECC from the researcher side, because of my professional background as a dentist in Peru, could lead to put more emphasis on one question than another, or prompt the respondents in some way that could influence their answers.

The small sample cannot be used to generalize results to the whole roster of dentists and dental hygienists that practice in Alberta. However, the fact that representatives of their regulatory bodies or associations, undergraduate professional educators and experts in both DV

and ECC were included in the study, created a fairly comprehensive picture of the current situation in Alberta with respect to the research questions.

Conclusion

The intersection of ECC and DV by dentists, dental hygienists, their regulatory bodies, oral health professional leaders and DV experts in Alberta; is framed separately. Participants’ discussion of ECC was consistent with the literature. Participants’ discussion of DV varied. Five gaps that made the intersection of ECC and DV a difficult subject to address were identified.

There is an existing legal framework that allows reporting DV and protects families from neglect and abuse. ECC could easily fall into the category of neglect or under the inability of the parent or caregiver to provide treatment. This legal framework is in place in Alberta to guide not only dentists and dental hygienists, but also other professionals; and it could be used when ECC intersects with DV in their client populations. Health promotion education and awareness of the issue of DV; inclusion of dentists and dental hygienists in this process, trying to get them involved in change will improve the current situation.

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Appendix A.

The full title of the project is: The intersection of early childhood caries and domestic violence: How dentists and dental hygienists in Alberta frame the issue.

Investigators: Dr. Ardene Robinson Vollman (Principal Investigator)

Carola Guardia Tello (Co-investigator)

This consent form is only part of the process of informed consent. It should give you the

basic idea of what the research is about and what your participation will involve. If you

would like more detail about something mention here, or information not included here,

please ask. Take the time to read this carefully and to understand any accompanying

information. You will receive a copy of this form.

BACKGROUND

Literature suggest that there is an intersection between development of early childhood

caries (ECC), a severe and aggressive type of tooth decay that affects mostly children

under the age of 5 and growing up in families with a history of domestic violence (DV).

Although this intersection has not been proved, and the literature is scarce, there are other

factors that could be influencing the lack of recognition of the link between ECC and DV.

WHAT IS THE PURPOSE OF THE STUDY?

The purpose if this interview is to acquire your perspectives on ECC and DV and if you

consider that both issues intersect at any point. And also if you know what regulations,

policies and protocols are in place in Alberta to guide dentists and dental hygienists when

ECC intersects with DV in their client populations.

WHAT WOULD I HAVE TO DO?

Through a 60 minute individual interview you will be asked about:

The knowledge of dentists and/or dental hygienists about the intersection of ECC and

DV.

Regulations, policies, and procedures of regulatory bodies, professional associations and dental leaders in Alberta Health Services regarding ECC and DV (separately and together); and How experts in the DV field in Alberta view the intersection of ECC and

DV (if any).

We remind you that we will be recording this interview with your agreement.

WHAT ARE THE RISKS?

The risks involved in this study are the ones pertaining to anonymity. These issues will be mitigated by the use of numerical identifiers. All the information will be stored in a password protected computer that will be keep in a locked space. You will not be identified in the report. Any quotes we use will be anonymised.

WILL I BENEFIT IF I TAKE PART?

If you agree to participate in this study there may or may not be a direct benefit to you.

The information we get from this study may help us to understand how the intersection of

ECC and DV is framed.

DO I HAVE TO PARTICIPATE?

No, you can decide not to participate in the interview; your participation is completely voluntary. If you choose to participate you are able to withdraw from participation without penalty at any time before or during the interview without providing a reason.

You do not have to respond to every question.

WHAT ELSE DOES MY PARTICIPATION INVOLVE?

Nothing else but setting an appointment time for the telephone contact.

WILL I BE PAID FOR PARTICIPATING, OR DO I HAVE TO PAY FOR

ANYTHING?

No. A research team member will contact you with the details. There is no cost to you if

you use a land line. Unfortunately we are not able to reimburse cell phone costs.

WILL MY RECORDS BE KEPT PRIVATE?

All efforts to ensure anonymity have been taken and you will not be identified by name.

Each participant has been provided with a number. These numbers are linked to your

contact information in a database accessible only to the researchers; the database file is

password-protected, and the file is stored on a password protected computer in a secure

location.

QUESTIONS OR CONCERNS

If you have any questions concerning your rights as a possible participant in this

evaluation, please contact the Director of the Office of Medical Bioethics, 403-220-7990.

If you prefer to avoid long distance charges please e-mail [email protected] and put

(Ethics ID#) in the subject line. Further information can also be received from Dr. Ardene

Robinson Vollman whose number is 403-xxx-xxxx, and email address is

[email protected]

SIGNATURES

Your signature on this form indicates that you have understood to your satisfaction the

information regarding your participation in the research project and agree to participate as

a subject. In no way does this waive your legal rights nor release the investigators or

involved institutions from their legal and professional responsibilities. You are free to

withdraw from the study at any time .If you have further questions concerning matters

related to this research, please contact:

Dr. Ardene Robinson Vollman (403) xxx-xxxx

If you have any questions concerning your rights as a possible participant in this research,

please contact The Chair of the Conjoint Health Research Ethics Board at the Office of

Medical Bioethics, 403-220-7990 or the Ethics Resource Officer, Internal Awards,

Research Services, University of Calgary, at (403)-220-3782.

Participant’s Name (printed) Signature and Date

Investigator/Delegate’s Name Signature and Date

(printed)

The University of Calgary Conjoint Health Research Ethics Board has approved this

research study. A signed copy of this consent form has been/will be given to you to keep for your records and reference.

Appendix B.

Template Script for Interview: Interview Guide

1. When you think about domestic violence (DV), what first comes to mind?

a. Probe for a definition of domestic violence

b. Probe for the causal interpretations of DV

c. Probe for moral evaluation on DV

d. Do dental health professionals have a role to play in interventions for DV

– e.g., awareness, reporting, follow-up?

2. When you think about early childhood caries (ECC), what first comes to mind?

a. Probe for a definition for early childhood caries

b. Probe for the causal interpretations of ECC

c. Probe for moral evaluation on ECC

3. Based on your experience or what you have heard from others in the field, have you any reason to think that there might be a link between ECC and DV in some cases?

4. Do you feel confident, comfortable, and competent to deal with incidents of DV in your practice?( If applicable)

a. Have any of these incidents involved children with ECC?

b. What regulations, policies, and protocols are in place in Alberta and or

Canada to guide dentists and dental hygienists when they experience situations of

DV in their client populations?

c. Have you had opportunity to refer to these at any time?

5. Do you have any concerns that ECC and DV are linked?

6. In your opinion, is action on the link between ECC and DV of urgency to dental health professionals?

a. If yes, why? And what could or should be done to intervene?

b. If no, why not?