This study was based on a randomized selection of public health nurses working in child health clinics in Norway. The aims were to describe oral health counselling to parents with infants and toddlers, to explore potential existing collaboration in oral health matters between nurses and personnel in the PDS regarding oral examinations of children and the frequency of referral of children with oral health problems to the PDS. An additional aim was to evaluate to what extent oral health was integrated in the basic public health educational curriculum in Norway. On a national basis, this study was the first randomized selected study focusing on the position of oral health in general health promotion provided by nurses in Norway.
The findings clearly showed that the nurses did not consider oral health to be among the first priority counselling subjects targeting parents of 0 - 2-yr-old children. Likewise, oral health was not a subject parents frequently talked about on their own initiative. Though the guidelines of the Directorate of Health [6
] recommend nurses to include many different health topics in their counselling, seventy percent reported (agreed or totally agreed) that they managed to give the information the parents of 1-yr-old children needed. Further, most of the nurses (72%) believed that the information they gave, had an impact on parents' health behaviours. Seven nurses responded that they agreed with the statement that the information they gave, only to a small extent influenced the parents' health behaviour. Lack of time was mentioned as being a main barrier to successful counselling. Approximately half of the nurses (48%) had regular contact with PDS for the 0 - 3 year-old group of children. Contrary to the guidelines of Directorate of Health, children's teeth were not routinely examined at all child clinics; only a quarter of the nurses claimed this was done. The study also showed conclusively that oral health occupied a minor position in the educational curriculum for public health nurses; at several institutions, the subject was totally absent.
The major methodological limitation of this study was the low response rate and the lack of information about the non-respondents. The methodological strength was that the study was based on a randomized sampling, lowering some of the scientific concerns related to systematic differences between the respondents and the non-respondents. Nevertheless, this high proportion of non-responses in the study made it unwise to regard this study as a national survey, which was the original goal. Still some background information given from a group of The Norwegian Nurses Organisation's Professional Interest Group of Public Health Nurses tended towards representativeness. They could report that the mean age in the current Norwegian population of public health nurses (N = 2853) was 49 years, which corresponded to the mean age of the public health nurses participating in the study.
On the other hand, the low response rate may reflect the finding that nurses did not prioritize oral health.
The lack of theoretical models in the construction of the questionnaire has its natural explanations: a collaborative team with members from the Directorate of Health and the Faculty of Dentistry, University of Oslo, had requested that the focus be on the topics presented in the questionnaire. Future work aiming to reveal more in-depth knowledge about the nurses' role in oral health promotion will include questionnaires based on conceptual frames.
In spite of the limitations mentioned, the current data set provides important new information about the role of oral health in general health promotion for parents with 0 - 2 year-old children. The knowledge of what kind of oral health information nurses offer parents of infants and toddlers and routines they follow in oral health matters has hitherto been scarce.
Sixty per cent of the nurses in the present study chose nutrition (breastfeeding and diet) as the health subjects most frequently included in counselling during the child's first year, followed by child development. If the link between poor oral health, nutritional problems and being underweight [13
] had been more frequently discussed and understated in media and in public, the nurses might have given oral health counselling higher priority. More emphasis of the fact that dental caries is a lifestyle disease [15
], sharing risk factors with other diseases like obesity and diabetes, might well have enhanced interest in oral health. The document "Global goals for oral health 2020" [16
] recommends the Common Risk Factor Approach in achieving the objectives of integrating oral health promotion and care in an overall strategy to influence health. A symposium on ECC in 2010 by the American Dental Association [17
] has gone so far as to define ECC as a paediatric infectious disease with dental manifestations rather than a strictly dental disease. Such a definition might have led to a strengthening of the role of oral health promotion.
The majority of the nurses displayed self-confidence when giving information influencing parental behaviour. To achieve results in various settings, self-confidence is considered to be important. For example, with respect to parents' self-belief (parental efficacy), a study has demonstrated that parental beliefs control brushing and snacking habits, and actually were predictive of these behaviours [18
]. According to some scientists, parental efficacy is believed to serve as a catalyst for initiating parental involvement [19
]. It was Bandura [20
] who, as early as 1989, introduced the original "self-efficacy" concept as "the subjective belief of the individual to be able to carry out a specific behaviour." On account of this, attention might be turned to enhancing the self-belief of those nurses who considered their own counselling as questionable in achieving behavioural change. It is nevertheless uncertain whether all those who believed they could influence parental behaviour succeeded, because the nurses participating in this study had not received any organized training in oral health promotion and counselling. It was also interesting to note that, concerning evaluation of their own practices, most of the nurses assessed themselves as having sufficient knowledge about oral health to advise parents correctly.
Advice about diet composition seemed to be the option most often selected in nutrition counselling with just a minor focus on sugar. This is worrying, because young children are known to be especially vulnerable to the destructive effects of sugar snacking [3
] and caries activity is closely correlated with dietary practices [22
]. On the other hand, it was a positive finding that so many nurses would recommend parents of toddlers to use water between meals and at night, and to start tooth-brushing as soon as the first tooth had erupted. The literature reveals that there is some confusion among nurses with regard to information about optimal fluoride exposure [23
]. The responses in this study did not clarify whether the nurses were unsure or lacked confidence about fluoride policy. Competing demands for time during clinic visits has been mentioned in other studies as a common problem [7
]. Other researchers have claimed that dental screenings make a good contribution to the overall oral health of young children and can easily be incorporated into a busy paediatric practice [24
In disadvantaged groups with unfavourable parental oral attitudes, referrals to or collaboration with the PDS should include meeting mothers shortly after delivery, or even expectant mothers [25
]. In Arkansas (USA), an ongoing free text message service provides weekly health tips for both pregnant women and new mothers. What is positive is that oral health is included among the topics, thereby signalling the fact that oral health is an integral part of general health[26
When dental examinations were conducted, they mostly took place at the 2 - yr visit, which was in line with the published guidelines. Optimal preventive outcomes could be expected if the recommended initial dental inspection were advanced to 1 year of age. One might speculate that indifference to oral health in non-respondents could be one reason for not taking part in the study.
A US study focusing on the role of paediatric primary care providers in oral health promotion showed that as many as thirty per cent of children who had oral disease were not referred for dental care [24
]. This may indicate communication obstacles between paediatric health workers and dentists. The present study was consistent with this finding. More than half of the nurses (52%) had no regular contact with the personnel in PDS about children 0 - 3 years of age, only four nurses said they often
referred children to the PDS before 3 years of age, and almost three-quarters of the nurses reported that they seldom or never communicated with dentists or hygienists about children who missed scheduled appointments in the PDS. Additionally, the nurses with high proportion of children with immigrant background in their charge, populations with expected high caries burdens [27
], did not refer a higher proportion to the PDS than other nurses. This is worrying, because in many minority groups, parental perceptions, oral health related knowledge and motivation for oral health are shown to be insufficient [28
], underlining the need of those groups for support and guidance in oral health matters.
On a positive note, there are studies documenting that interventions in oral health training can have favourable direct impacts on ECC. A study performed at a paediatric outpatient clinic in USA has confirmed that a relatively brief intervention of counselling communication skill training was associated with increased provider knowledge and counselling. This again resulted in a significantly attenuated occurrence of ECC [7
]. The authors also claimed that it was not enough to teach nurses oral health knowledge. If parents are to achieve a change in behaviour to reduce ECC risk, nurses must translate their acquired oral health knowledge into changed behaviour. To reduce disparities in treatment provided and outcomes between underprivileged groups and others, there must be greater focus on communication with parents, including cultural competency of care providers and the health literacy and health beliefs of parents. The barriers may be at the system level, the personal care level or the provider level [29
Nurses' confidence to identify and to refer children appropriately with oral health problems has also been documented to be of importance [30
], as well as knowledge about ECC and awareness of how important good oral health is for children's wellbeing and quality of life.
The information gathered in this study suggests that oral health is not seen as an integrated part of general health at all educational institutions. Three out of the eight national institutions did not have oral health in their educational curriculum. In light of this finding, it is understandable, however undesirable, that not all nurses are sufficiently engaged in oral health promotion to make it a priority subject in counselling. This finding was also in accordance with shortcomings regarding health schools in the UK, where policymakers at a national level have excluded oral health from guidance[31
Approved guidelines in paediatric dentistry [32
] are clear that early caries identification and interventions of non-invasive care are required to reduce the occurrence of ECC. Appropriate preventive measures may allow a natural arrest of caries while still confined to enamel [33
]. To allow the identification of factors that identify individuals at highest risk of caries, the best choice is to see children prior to or very shortly after teeth have erupted. As oral health risk groups frequently include immigrants, these people form natural target groups for culturally tailored prevention strategies [34
]. The current data set showed that established previous contact in one form or other with PDS enhanced the likelihood of nurses referring children before the age of three years. This is a reminder of the importance of collaboration between nurses and the personnel in the PDS.