Dentists' Perspectives on the Manitoba Dental Association's Free First Visit Program

The American Academy of Pediatric Dentistry first introduced the concept of the "dental home" for children in 1986; it currently recommends a first dental visit by 12 months of age.^1-3 Today, several professional organizations, including the Canadian Dental Association, recommend an early dental visit within 6 months of first tooth eruption or by 12 months of age.^4,5 This recommendation helps to introduce the concept of a dental home for children and provides opportunities to prevent early childhood caries through risk assessment and caregiver education.^3,4

The establishment of a dental home in infancy is important to set the foundation for good oral health during childhood. Early assessment, preventive care and anticipatory guidance can protect primary teeth by decreasing exposure to cariogenic factors and instill good oral health habits. Furthermore, children whose first dental visit occurs by the recommended 1 year of age have lower rates of restorative and emergency treatment over childhood compared with children do not visit a dentist until 2–3 years of age.^6,7 Evidence suggests that early preventive dental visits can reduce the need for restorative and emergency care, therefore reducing dental-related costs among high-risk children.⁷ Unfortunately, many Manitoba children develop caries, and a considerable proportion develop severe early caries that requires treatment under general anesthesia.⁸ The average rate of dental surgery to treat severe early childhood caries in the province is 30 per 1000 preschool children, but it exceeds 100 per 1000 preschool children in northern regions of the province.⁸

Unfortunately, early dental visits are still uncommon for children in Canada.⁹ A past survey of Manitoba dentists showed that only 58% were aware of the first visit by age 1 recommendation. In addition, fewer than half of respondents saw children younger than 12 months.¹⁰ These responses suggest that many practitioners in Manitoba may not see children in their offices by the recommended age.

In April 2010, the Manitoba Dental Association (MDA) implemented the Free First Visit (FFV) program as a 3-year pilot project.^11,12 This program provides access to free dental screening for children under 3 years of age to prevent decay in children's primary teeth, raise awareness of the first visit by age 1 concept and establish dental homes. During an FFV, children are given the opportunity to become comfortable with the dentist and have their teeth checked. Parents may receive information on caring for their children's teeth and discuss future dental treatments if needed. The FFV initiative was promoted through radio and television messages, bus ads and posters in dental offices. In preparation for the first visits, dentists were given educational materials on infant examinations and anticipatory guidance for caregivers. Approximately 235 general and pediatric dentists reported that they participated in the program.¹¹

The purpose of this study was to determine dentists' views of the FFV program.

Methods

We relied on qualitative methods, namely focus groups, to elicit the views of dentists on the FFV program. Participating and non-participating Manitoba dentists were invited to take part. This study was part of a larger mixed-methods evaluation of the program.

The research team involved members of the Healthy Smile Happy Child (HSHC) partnership, an intersectoral team promoting early childhood oral health in Manitoba.^11,13,14 The HSHC partnership was not directly involved in the MDA's FFV program except for the principal investigator (RJS) who served on the MDA's FFV committee. The research team contracted an independent qualitative researcher (GM) to facilitate and analyze the focus group discussions. The HSHC program coordinator assisted in recruiting dentists and was also present during the focus groups. Neither the coordinator nor the contracted researcher had a dental background.

Data were collected from a convenience sample of dentists using a semi-structured interview guide (Table 1). Questions were formulated in concert with HSHC staff and tested in a pilot interview conducted by telephone. This resulted in minor adjustments to the interview guide, such as re-ordering and clarifying some questions. Participants also completed a short questionnaire, which included years in practice, location and type of practice, number of preschool children seen in an average week and whether they participated in the FFV program.

Additional questions were asked to allow a fuller understanding of issues raised and to follow up on relevant, but unanticipated topics, as is standard procedure in qualitative research. The focus group interviews were audio-taped with participants' consent and subsequently transcribed. Field notes were written after each focus group.

Focus groups were held at the MDA Annual Convention in Winnipeg, Manitoba, in January 2012 to facilitate representation from throughout the province. Dentists were recruited in several ways, including email invitations and reminders to all MDA members. Potential participants were asked to respond directly to the facilitator to ensure confidentiality. The focus groups were also publicized at a booth at the convention and on-site invitations were distributed to attendees at the conference.

Field notes and interview transcripts were reviewed, and participants' comments were coded and categorized to identify topics and patterns that could be developed into themes. N-Vivo was used to assist with organizing the data (version 2.0.163; QSR International Pty, Ltd., Cambridge, Mass.). Quotations were edited to improve readability.

All participants provided written informed consent and received a small honorarium. The study was approved by the Health Research Ethics Board, University of Manitoba.

Results

Three focus groups and 1 pilot interview were conducted with 30 dentists. Focus group discussions averaged 60 minutes. Of the focus group participants, half practised in urban areas, one-third in rural areas and 15% in northern Manitoba, with some dentists practising in more than one location (Table 2). During the focus groups, some non-participating dentists commented that they had participated in a previous program or that they provided free visits even though they were not formally part of the FFV program.

Analysis of the focus group transcripts revealed common themes, which are presented below.

Reasons for Participation (or Not)

Most focus group members (24/30) participated in the FFV program. Both participants and non-participants were extremely supportive of the program. Some non-participants indicated that if their work situation were different they would join. Many participants made this type of comment: "Our office participates because we think it's a good program." Some dentists indicated support even though most of their patients were not aware of the program. Typical comments were:

Yeah, I do it because it's a good public health measure. Also, I think it's a great idea. I don't think patients really know about it. But it's a great idea, that's why I do it.

It's good for the professionals, a good image.

The most common reason for participating in the FFV program was because it promoted early dental visits. Dentists said the program helped them educate parents about the appropriate age for a first visit and how to care for their child's teeth. The first visit also accustomed the child to the dental office in a non-threatening situation. Several dentists referred to the importance of establishing a "dental home."

To me the benefit of the program is the public awareness.

I participate because I find it's a good idea to get the kids in early so that we can teach the parents about prevention.

Although not a universal view, many agreed that it only took a few minutes to perform an examination. However, several dentists said that they encountered toddlers with serious decay leading to lengthier and more difficult first visits.

One participant said that even though he already provided free visits, he appreciated the formal program because it eased parents' worries about being billed and, thus, increased their level of comfort in bringing in their toddler. Several dentists indicated they were already providing free visits, so they just continued. Others said they joined because the MDA or parents asked them to.

There are 4 dentists in the clinic, and I'm the only one who does it. But the reason I did it was because I had a couple of parents who'd come in and they asked about it.

I just participate because the MDA had sent out a letter asking for people to, and I figured that if the MDA is advertising a program, and if someone comes to me and asks me about it, then it would make sense that I'm going to do it.

Some dentists noted that publicizing their participation in the FFV program could attract new patients: "A lot of people just do it to attract parents to their practice." One dentist, who participated because of patients' expectations, reported it as a positive experience:

I've found that it's kind of a nice thing to have people come in and see 3 year olds. It's very fast and quick, and it's kind of fun. And they bring something to my practice in that because I participate in it, I think that there might be some families that just come first for their kids, and then we ask them, and some of them come as well.

Of the 6 dentists not formally registered in the program, several said that they offer free visits. Several mentioned filling out FFV tracking forms as an issue: "As silly as it sounds, the reason that we don't do the program is because we don't want to have to track the forms, because we already offer those visits for free." Several dentists said they did not participate because their practice consisted of older patients. Another indicated that his/her rural office was too busy:

The office chose not to participate because, and I apologize for saying this, but if we did advertise as free first visit we wouldn't have time to see other patients. And then if we did diagnose caries, and I'm sad to say this but there are a lot of children in rural Manitoba who have caries, it wouldn't make a difference because those parents can't pay for the treatment and there's no other options for them, out in rural Manitoba.

One dentist said that many pediatric dental practices include a majority of patients whose bills are covered by a third party, including First Nations patients, patients on social assistance and those with insurance. "If you saw 1 or 2 a day or a week, it's no big deal, but if three-quarters of your patients are from this group.… Why are you advertising it to the public group that it's free, when in fact it's free already?" Foregoing payment in these cases could create financial problems for the practice without providing any benefit for patients.

This dentist lamented that the structure of the program prevented him from participating. He wanted to be able to publicize the FFV to private clients, but continue to charge government and insurance companies for patients with coverage. Other dentists recognized this issue as a legitimate concern.

Uptake and Follow Up

Many focus group participants believed that public demand for the FFV is low. Three said that they had not yet had any preschool patients; nearly half (13) said they saw 5 or fewer in an average week. Some practices comprise mostly older adults, and low uptake of the FFV was expected. Other reasons given for low demand were that most parents remain unaware of the program, and most still do not know that infant and toddler checkups are recommended.

Most dentists said that most FFVs were provided to families that were already part of their practice. Although these patients would have attended anyway, they were pleased to learn the visit would be free.

Several dentists thought that the program might have attracted a few new patients to their office and brought in some children earlier than otherwise. They also cited the program for helping them to promote early visits.

They may be looked at earlier, and that's great; that's a good objective and that we are a part of this is good.

The big value of the program is to catch them, ideally before the teeth even turn up. If you've got 1 or 2 [year old], there's nothing to do. The ideal is to keep it that way because you're trying to keep them caries free.

With respect to follow-up visits, dentists said that parents with insurance returned, but those without insurance often did not come back.

Some people come in for their free first visit because it's free. But then, if they actually have to have work done and pay for it, they aren't quite so enthusiastic because as [someone here] said, it's baby teeth. So the free first visit is fine because it's free but then to follow up sometimes is a different story.

Access to Care

Both general and pediatric dentists said that most (75–90%) of their patients had some form of coverage: private or government-based insurance. However, patients without coverage present challenges. Dentists described how parents of these patients come in for the first visit because it is free, learn of extensive treatment needs and then do not return because they cannot afford the treatment. Although dentists value providing some education to families, the overall experience is frustrating to them as well as to the parents. Dentists want to see that these patients receive the treatment they need.

There was overall agreement that the program did not improve access to care for patients in disadvantaged circumstances.

I don't think it increases access to care. It's a pretend help. … What we're doing to the kids is we're giving them a free visit with nothing beyond that.

What do we do for those people? So, it's all smoke and mirrors to make everybody feel better, that dentistry is doing something to help the public… The individuals who actually need treatment can't afford the treatment. So why make that first visit free?

Although there was consensus that the FFV program did not improve access to care for disadvantaged families, dentists seemed to agree that this was not an appropriate goal for the program. "I don't think we should think that a program like this is about access to care. It's about dental awareness."

Public Awareness

It was clear that participants viewed the goals of the program as increasing public awareness, educating parents to prevent early childhood caries and allowing early diagnoses to prevent major problems. Several dentists discussed the probability of saving money if children's needs were addressed earlier. Creating a dental home for children and increasing their level of comfort while visiting the dentist were mentioned frequently and, as indicated above, were the incentive for many dentists to participate in the program. Some dentists also believed that the FFV had value as a goodwill gesture from dentists to the general public. These were viewed as appropriate goals for the program.

More prevention, to me it's all about prevention, to put more money in prevention because we have under 3s that come with mouths already destroyed, extractions, crowns. So why don't we start from the beginning when parents are pregnant — teach them what to do to prevent all these.

I hardly do a real exam. It's merely looking in the mouth, as much as the kid will let me do without overpowering them.… I just need them to feel that this is a safe place.… So, hopefully, they will like coming to the dentist and they [will] feel comfortable in that place. As you said, the dental home, they feel at home.

First Visit by Age 1 and Free Under 3

There was consensus that the message about the need for a first visit to the dentist by 1 year of age had been lost in the FFV program's advertising. The "free under 3" message had eclipsed that more important message. Some focus group participants remarked that even parents who were aware of the FFV program were unaware of the recommended age for a first visit. Dentists were consistent that the key message should be visit your dentist before the age of 1 or 6 months after eruption of the first tooth.

I think that the program has lost what it really set out to do, that being to establish a dental home for children and to have them have their first visit by the age of 1. Lots of people are reading it, that it's free before 3 and they're waiting too long to bring their kids to a dentist's office.… The message should be that your child needs a checkup by age 1 to establish a dental home.

A lot of parents see "free first visit under 3," and even though in the fine print we recommend at 1 year, they think, "Oh we have until age 3 to come in."… Parents are surprised that it's recommended at 1 year.... They say, "Oh, I thought it was 3" because that's all they see.

One dentist emphasized how little time the public had to absorb the media advertising. He said:

Billboards should have an emphasis that your child should be seen either when their first tooth comes through or by 1 year. But if you push that [message] out there on the bus, people just see it go by for what, 5 seconds. And that's it. And then it's gone, and the bus drives away. You've got 5 seconds to capture that audience, so if you see 3 [that's what you remember].

In 2 of the focus groups, dentists discussed reversing the emphasis in the advertising campaign. They wanted more emphasis on first visit before age 1, and less on "free under 3," although they still wanted both messages included.

Something like, kids should have their first dental visit by the age of 1, but come to the dentist before 3 and your visit will be free. Something like that.

There were different opinions on the cut-off age for free visits. All agreed that 3 years was too late for a first visit. Some wanted the free visit to be for children under 18 or 24 months to encourage parents to bring their children in sooner. This suggestion elicited both support and disapproval in the 2 groups where it was raised. Those who were satisfied with 3 as the upper limit for free visits wanted the message to emphasize age 1 as the appropriate age for a visit, but were worried that if the age for the free visit was lowered, at-risk children might be missed altogether.

All I really see is just it's free if you're under 3 and really not much detail. Maybe put a little more information out there, like bring your kids in earlier and we can get on the right track.… Having it till age 3 is good, but emphasizing the earlier you touch base with the dentist, the better your child's outlook is throughout their life.

All agreed that the earlier a child visits the dentist, the better. Many participants suggested that this topic be raised during a pregnant woman's dental visit and a brochure emphasizing appropriate care be provided. Some said they discussed this issue in prenatal lectures. To this end, they wanted new mothers to receive a pamphlet in the hospital with 1 strong message: visit the dentist by age 1. They recommended simplicity in posters and pamphlets with the main focus on the age of the first visit and "free under 3" as a secondary message in smaller print. They wanted obstetricians and pediatricians to display posters emphasizing the appropriate age for a child's first visit in their waiting rooms.

Participants also wanted pediatricians and public health nurses to check whether their young patients had visited the dentist at the appropriate age and follow up with encouragement and reminders if needed.

Impact of FFV on Dentists

Most dentists said that the MDA's promotion of the FFV program had not altered their awareness or practice. There was a suggestion that the age for seeing children had changed relatively recently. As 1 dentist put it, "We used to always say years ago, that 3 years of age was the time to come, and I think that was ingrained in people's minds." It was interesting that there was consensus that parents should be encouraged to bring their children to a dentist at or before age 1.

The expense associated with the program was a major challenge for a few dentists: cost of supplies in addition to staff time. One dentist pointed out that giving away 300–400 toothbrushes could add up.

It was pointed out that most FFVs are performed by pediatric dentists. One pediatric dentist said that she could do FFVs all day, so had to cut back on the number she was seeing. As already discussed, some pediatric dentists may choose not to participate formally in the FFV program because they do not want to lose third-party payments. Meanwhile, many pediatric dentists commented that they wanted to see more general practice dentists do more screening of young children.

The area to really improve is to try and get kids more into the general practice offices.… I'm looking at some numbers here from the report for the committees here for the MDA.… And 65% of the kids that we're seeing under this program were from pediatric offices, which only represent a very small part of the population of dentists. So, it is really skewed… but I think that is something to be addressed here. We really want to catch kids in the general practice.

Several specialists wondered if general dentists were comfortable examining very young children, and general practice dentists raised this point too. When 1 dentist commented on "the general challenge of just getting into the mouth of a 15-month-old," heads nodded all around the table, and someone added, "That's why there are specialists."

Another pediatric dentist wondered if general practice dentists had sufficient information to respond to questions that might come up. He, and several other dentists, recommended a package of information for dentists. In addition, several pediatric dentists wanted to ensure that training for working with this age group was appropriate. One suggested that students should work with this age group during their undergraduate training.

I know it's probably beyond the scope of this committee, but 1 thing that I'd like to see is that the dental students who are educated in undergraduate pediatric dentistry should get exposed to treating kids, excuse me, examining kids under the age of 3. I don't believe it's currently set up within the curriculum. But I think that would make a big difference to the new grads who are coming out, to feel more comfortable, and actually wanting to take those kids and put them on their lap.

Discussion

Overall, dentists were enthusiastic about the FFV program and there was general support for its continuation. Focus group participants also said the program helped to raise public awareness about the recommended timing for a child's first dental visit. The FFV campaign may also have helped keep dentists up to date with current recommendations, as a survey of Manitoba dentists conducted after the program's first year showed increased awareness of age recommendations for first dental visits: 86.3%, up from 58% in past surveys.^10,11 Further, the average age for a first visit recommended in their practices has decreased significantly over time (18.9 vs. 24.8 months) and is only 6.9 months later than the age 1 recommendation.¹¹

It appears that, over time, dentists are becoming more aware of prevention and management techniques related to infants and toddlers.¹¹ Although this illustrates dentistry's movement toward promoting earlier, preventive dental visits in Manitoba, there is still room for improvement. Unfortunately, despite growing awareness in the broader oral health community about the age 1 visit, many Canadian children are likely not benefiting from early examinations.⁹ However, evidence from the first 3 years of the FFV program indicates that more Manitoba toddlers are benefiting from early examinations.¹² Most dentists indicated that they participate in the FFV program and the main reason for taking part is to promote early dental visits for children.

Dentists viewed the program as a good public health measure and a way to bring in greater numbers of young children for early dental visits. They felt that the FFV program helps educate parents and promote caries prevention while also developing the child's comfort in the dental chair. Other dentists cited such reasons for participating as improving public awareness, because parents asked them to join and because the FFV is a goodwill gesture that improves the image of dental professionals. One of the reasons given for not participating was simply the practice consists of an older patient population. Other non-participants said they already give first visits for free and did not want to fill out the tracking forms. One rural office was too busy for free visits; the dentists would not have enough time to see their regular patients if FFVs were advertised.

Other barriers to taking part in the FFV program included the expense associated with the program and not being comfortable performing infant dental exams. Some dentists did not want to lose out on third-party payments for patients who already had coverage. These responses are consistent with findings of recent surveys in which dentists reported feeling uncomfortable with young children, especially caring for crying children.^15,16 Dentists also recognized that another barrier to early visits was lack of parental interest or awareness of their importance.^10,16,17 Factors, such as financial and time constraints, often keep dentists from providing early visits in their offices.^11,16,17

Although both general practice and pediatric dentists participated in the FFV program and the program was intended to increase the participation of general dentists, pediatric dentists account for most of these visits. Whereas general practice dentists reported seeing an average of 7 children a week, pediatric dentists saw 16.5 preschool children a week on average. Our analysis of submitted FFV tracking forms similarly showed that fewer than 25% of FFVs were provided by general dentists.¹³

Participants in this focus group study suggested that increasing general practice dentists' comfort with performing infant examinations might lead to their greater involvement in providing FFV visits in their offices and increase access to care.¹⁷ One way to accomplish this would be providing education on infant oral health care and instruction in performing infant dental exams through information packages and undergraduate training.¹⁸

Another concern raised by dentists was the potential for sending mixed messages with the FFV campaign promotional materials. The FFV program was widely advertised in the media. Dentists felt that the "free under 3" message was overshadowing the first visit by age 1 recommendation. Parents who were aware of the FFV for children under 3 years were often surprised to learn about the recommendation for a first visit by 12 months. Dentists wanted FFV messaging to focus more on the "come by 1" concept, with "free under 3" as a secondary message. Health promotion information geared to the public must have clear and targeted messaging that is concise and understandable and supports best practice.

Although dentists in this study stated that most parents were unaware of the FFV program, a recent series of focus groups with parents and caregivers undertaken as part of the overall mixed-methods evaluation of the FFV program revealed that nearly all were aware¹⁹. These parents reported that they had heard about the program through word of mouth and media advertising. However, although the sample of parents interviewed were aware of the FFV program, over half chose not to participate because there were no current issues with their child's teeth. This may indicate a need to educate parents further regarding the importance and rationale for early preventive dental visits.

This report is based on 3 focus groups. Although the small sample may limit the generalizability of the results, there was a high degree of agreement within and between focus groups on many of the issues discussed. The sampling procedure may have attracted dentists who were the most interested in, committed to or positive about the FFV program, resulting in the potential for overestimating enthusiasm for the program. Dentists with strong negative views may not have felt comfortable participating in a focus group. However, the letter of invitation provided alternative contact options. Also, there was a high degree of consensus despite the inclusion of 6 dentists who did not participate in the program and a number who did at a variety of levels, including no patient uptake. Conducting these focus group sessions in conjunction with a professional meeting and offering an honorarium for participation was successful in drawing dentists working in urban, rural and northern situations, general and pediatric practitioners and dentists with a broad range of years in practice. The wide provincial representation increases confidence that recruitment attracted a good cross-section of dentists.

A strength of qualitative research is the ability of participants to raise issues they feel are important, which allows relevant critiques that might be missed in other methods. Citing dentists verbatim helps convey their perspectives in context. Interaction in a focus group allows participants to react to each other's comments, which can deepen responses and draw out differences. Although this can be a disadvantage if 1 or 2 members dominate the discussion and sway participants, having several focus groups offsets this possibility.

Findings from our mixed-methods evaluation of the FFV program, including results from focus groups with dentists and parents, were shared with the MDA, its board and communications committee and the FFV program committee on numerous occasions. Our inclusion and engagement of the MDA as a partner and knowledge user group at the early planning stages of this study is a testament to our desire for true integrated knowledge transfer.

Final recommendations that were presented to and discussed with the MDA included the need to continue with this initiative, to tailor messaging to the public and profession so that emphasis is placed on the importance of the first visit no later than 12 months of age and to continue to increase general dentists' ability to work with young children.

THE AUTHORS

	Dr. Schroth is associate professor, department of preventive dental science, college of dentistry, and department of pediatrics and child health, college of medicine, faculty of health sciences, University of Manitoba; and research scientist, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba.
	Ms. Guenther is project assistant, Healthy Smile Happy Child initiative, University of Manitoba; and research assistant, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba.
	Ms. Ndayisenga is project assistant, Healthy Smile Happy Child initiative, University of Manitoba; and research assistant Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba.
	Dr. Marchessault is private research consultant, Winnipeg, Manitoba.
	Ms. Prowse was project coordinator, Healthy Smile Happy Child initiative, University of Manitoba; and physical activity promotion coordinator, Winnipeg Regional Health Authority, Winnipeg, Manitoba.
	Dr. Hai-Santiago is provincial oral health consultant, Manitoba Department of Health, Healthy Living and Seniors, Winnipeg, Manitoba.
	Ms. Edwards is regional director, primary health care and chronic disease, Winnipeg Regional Health Authority; and special advisor to the deputy minister of health on primary care, Manitoba Department of Health, Healthy Living and Seniors Winnipeg, Manitoba.
	Dr. Moffatt is professor, department of community health sciences and department of pediatrics and child health, faculty of medicine, University of Manitoba; research scientist, Children's Hospital Research Institute of Manitoba; and executive director of research and applied learning, Winnipeg Regional Health Authority, Winnipeg, Manitoba.
	Manitoba Dental Association www.manitobadentist.ca

Acknowledgements: Operating grant funds for the evaluation of the FFV program were provided by the Manitoba Institute of Child Health. At the time of this study, RJS held a Manitoba Medical Service Foundation-Manitoba Health Research Council Clinical Research Professorship in Population Medicine. The authors would like to recognize the support of the Manitoba Dental Association's Free First Visit Committee, participating Manitoba dentists and members of the Healthy Smile Happy Child partnership.

Correspondence to: Dr. Robert J. Schroth, Associate Professor, Faculty of Health Sciences, Department of Preventive Dental Science, College of Dentistry, Department of Pediatrics & Child Health, College of Medicine, University of Manitoba, 507–715 McDermot Ave., Winnipeg MB  R3E 3P4. Email: umschrot@cc.umanitoba.ca.

This article has been peer reviewed.