Parents' online discussions about children's dental caries: A critical content analysis.

Milne, Avery ; Weijs, Cynthia A. ; Haines-Saah, Rebecca J. 等

The purpose of our study was to explore ways in which parents orient to (i.e., take up, challenge, re-articulate) information about child dental health in the context of online forums (Internet "discussion boards") focused on fostering information-sharing and online social connections among parents of young children. In this paper, we extend existing, critical scholarship on the workings of dental expertise, authority and power and apply those insights to the contemporary digital context of parenting forums. In doing so, our intent is to critically reflect on the gaps or disconnect between parents--namely mothers--and dental health professionals, and to consider how dental public health might learn from such online exchanges. This is important because it can signal ways for public health professionals to better engage with parents and families in the context of both "real time" interactions and digitally connected communities.

Theoretical framing

The theoretical framing for our manuscript builds on Nettleton's (1,2) engagement with Foucault to theorize face-to-face interactions between dentists and mothers. We aimed to extend and update Nettleton's insights by considering how the tensions between so-called "expert" and "lay" knowledge play out in online contexts. Nettleton's work positions dentistry as an exemplar of Foucault's concepts of governmentality and disciplinary power in the professional encounter. Based on qualitative interviews with mothers and dentists in the UK, Nettleton's analysis underscores how dentistry extends its professional surveillance over families beyond the professional encounter and into the private space of the home by recruiting mothers as "agents of dental health". This builds on Foucault's claims about governmentality as a disciplinary technique that extends the powers of the state beyond the crimino-legal domain, influencing citizens' "dreams and aspirations" about their futures, including their well-being and health. (1,p99)

Through her study of discursive practices within the context of the dental visit, Nettleton (1,2) highlighted how dentistry enacted authority over families, constructing them as both the subject and object of its campaigns. One illustration is the gathering of information about social circumstances through the dental examination, and then using it in targeting families--especially mothers--for various interventions couched in terms of health and dental hygiene, but also in terms of mothers as the "moral guardians" of family health (e.g., toothbrushing as "good for children"; a moral stance whereby "proper" health behaviours are equated with good and healthy families). In this way, governmentality provides a lens to understand how dentistry "co-opted" mothers for the regulation of oral hygiene in the home.

Exploring parents' online interactions related to dental health through Nettleton's Foucauldian lens allows us to contribute to theorization of engagement between the public and health professionals, and how this plays out in a digital context. Nettleton's work considers mothers not just as the targets of discourses from dentistry, but explores the complex ways in which women may simultaneously take up and resist professional interventions in the context of home and family life. To this end, a Foucauldian model of power as diffusive and enabling (i.e., not simply oppressive "power over") is helpful for considering the ways in which mothers' talk in online forums "pushes back" against some professional discourses (and yet reinforces or does not challenge others) in the context of online discussions with other parents.

Coupled with Nettleton's scholarship, our research rests on other foundational work in the sociology of health and illness which was critical in challenging the assumption that "health" is valued or experienced in the same way across social groups, (3,4) including but not limited to experts and non-experts. Though these divisions continue to exist and remain important, they have arguably become blurred in the digital context of information ubiquity and online engagement, which have fostered new opportunities for members of the public to mobilize around (and sometimes against) the projects of public health.

Study focus: Online parenting forums

Internet forums offer an accessible and potentially rich source of data collection for content analysis. According to the 2014 Fact Book of the Canadian Internet Registration Authority, Canadians are among the heaviest Internet users in the world, averaging about 41.3 hours per month online. (5) The 2012 Canadian Internet Use Survey found that 83% of Canadians have Internet access in their homes. (6) While the "digital divide" may have narrowed with the diffusion of Internet access, gaps and inequities that shape online participation remain, including access to hardware (i.e., cost, ability) and infrastructure (i.e., lack of broadband access in rural and remote communities). Thus, as noted by digital theorists such as Lupton, (7) though the apparent ubiquity of Internet use may give the illusion that it is democratizing and broadly empowering for the projects of health promotion and public health, forms of digital exclusion persist.

Online parenting (and especially "mothering") discussion forums have become a popular way for parents to build community, receive and provide social support, and exchange information and parenting advice, but they can also be fraught with tension in a context where relative anonymity can facilitate conflictual exchanges. A content analysis by Porter and Ispa (8) on two popular parenting forums in the United States found that the forum contributors, who were almost exclusively mothers, used the site to discuss topics such as feeding, eating, sleep, development, toilet-training, discipline, and mother-child relationships. Mothers also posted about parenting stress, discussed fears that their children were not developing normally, and questioned advice given to them by their doctors and paediatricians. Another content analysis, by Madge and O'Connor, (9) of a UK parenting site called Babyworld found that accessing this virtual social support and alternative information sources available online gave a sense of empowerment to women. Mothers interviewed explained it was a valuable source of both social and informational support, and they praised the convenience of being able to connect with people at any hour of the day, especially at "unsociable hours". Using a Bourdieusian social capital framework, Drentea and Moren-Cross (10) found that participating in online forums provides mothers with emotional support (e.g., consoling each other or normalizing experiences); instrumental support in the form of sharing personal experiences and anecdotes, and referencing professional experts and organizations; and community building and protection (where mothers sanction those who violate community norms with comments that appeared unsupportive or critical). Finally, in a study of postings over a seven-year period on an online community for mothers of children with sensory processing disorder, Zaslow (11) found that mothers challenged traditional epistemologies centered on objectivity and empiricism, and through the act of communicating, gave value to subjective, experiential and concrete ways of knowing.

Because contributors appear to be comfortable speaking honestly, (9) these forums create a unique research environment, with potential to access views and opinions that may be latent in everyday society. Therefore, an analysis of content posted online provides one way to gauge opinion and public discourse about health issues, especially due to the volume of posts made and the diversity of viewpoints found in online forums.

We might have focused this exploration on any number of controversial issues in public health (e.g., breastfeeding, vaccine hesitancy) as such topics garner significant social media discussion. We chose the issue of dental health for three reasons. First, dental caries is a significant public health concern. (12) Second, children under the age of five may not yet have had their first dental visit, so online forums may be a popular place for parents to access support for dental concerns about decay and its impacts. Finally, Nettleton's (1,2) work provided the theoretical foundation to explore those concepts in the digital environment.

METHODS

Online site selection

Based on an initial Google search of the terms "parenting forum" and "mothering forum", 21 forums were identified that were publicly available and had a search function for discussion content. We opted to focus on BabyCenter Canada (www.babycenter.ca) because it was the only such online community with forums devoted specifically to parenting/mothering in the Canadian context, and a preliminary look at its content indicated that it contained discussion related to dental health (including dental caries, related home care behaviours, and fluoride). BabyCenter Canada is the Canadian version of the larger family of highly trafficked BabyCenter websites targeted to users internationally, owned and operated by the Johnson & Johnson Corporation. (13) The site is popular in Canada, with 461 300 unique visitors to the site. (14) BabyCenter Canada describes their user forums as a place to "vent, get reassurance, and maybe even make some new friends." (15) To the extent that the site is successful in inviting open discussion and sharing of frustrations, it represents an avenue to explore viewpoints that contributors may not feel comfortable sharing with health professionals.

Data retrieval

Relevant dental health content was identified using the search terms related to our particular focus on children's dental caries (tooth decay), related home care behaviours (e.g., tooth brushing), and fluoride. The role and importance of the digital context is perhaps most obvious or magnified for controversial issues in public health, because it provides a readily available outlet for people with strong views to express those views and find like- minded online peers. Fluoride, as a controversial issue in public health, (16,17) was our lynchpin in that regard.

We searched for the following terms: "dentist"*, "fluoride" (and misspelling "flouride"), "toothpaste", "decay", and "cavity"/ "cavities". The search terms "brushing" and "caries" were also considered, but they often pulled up content that was not relevant to dental health (e.g., brushing hair, or figuratively "brushing" something off) and were therefore not used. Threads were excluded if they were about dental health of the mother, or if they were unrelated to dental health (e.g., discussions of the uterine "cavity").

Data analysis

The discussion thread (i.e., a first posting and the follow-up responses and comments) was the unit of analysis (Figure 1). NVivo qualitative analysis software was used to organize and code the data from forums and our coding process was iterative in nature, involving several cycles through the data. We coded the data hierarchically (Table 1). Threads that covered multiple subtopics were given multiple second-level codes.

We applied a critical social science lens to our analysis, informed by Nettleton's (1,2) work on authority and power in the dental realm. From the outset, we had two general interests; first, we were interested in how parenting forum participants positioned themselves vis-a-vis dental knowledge, including expert knowledge from scientific research and clinical encounters, as well as how parents took up and advised others about practices they found helpful. We were also interested in whether and how the content of the postings explicitly and implicitly constructed child dental health as the responsibility of mothers. The resulting themes reflect these a priori interests of the team. The research team--which comprised different levels of experience (junior trainee, senior trainee, early-career, and mid-career researchers), multiple disciplines (clinical dental hygiene, sociology, population/public health, gender studies, and equity) and methodological orientations (qualitative, quantitative)--discussed the preliminary themes to develop them further, and reflected on the data collected from the forum postings in an iterative, team-based analysis process.

To ensure the quality of our research, we used Noble and Smith's criteria for establishing rigour in qualitative work.18 To enhance the truth-value of our research, we provide contributors' full quotes, without editing them in any way other than length, to allow the quotes to remain as true to their original poster's intent as possible. To maintain consistency, we created an "audit trail" by keeping a journal, during data collection and analysis, of decisions made as the project progressed. Analytic rigour was enhanced by our adoption of a theoretically-informed approach to qualitative analysis (19) and our collaborative team effort, as noted above.

Research Ethics Board approval was not required for this study because researchers did not participate in forums or interact with members, the results did not identify individuals, and the forums are in the public domain.

RESULTS

A total of 1053 threads were identified. After applying the inclusion criteria, 479 remaining relevant threads were downloaded into NVivo using the NCapture web browser plugin (duplicates were omitted). We focus here on topic areas that were prominent in the forum discussions (i.e., when to first visit the dentist, issues of brushing and toothpaste, breastfeeding to sleep and night feeding as related to decay) to unpack our two themes of interest (Figure 2).

Theme 1: Mothers' relation to health professional recommendations--Alignment, resistance and conflict

Mothers often discussed, with each other, advice given to them by dental health professionals or doctors. These discussions spanned three main topics--child's first dental visit, toothbrushing and toothpaste, and breastfeeding as related to decay. Agreement or disagreement seemed to depend on several factors, including what mothers themselves knew was the "best" or healthy choice for their child; mothers' efforts to incorporate several other sources of information along with their health professional's recommendation; and what was feasible within their family context.

Dental professionals' varying advice about the appropriate age for a child's first visit (the ages 6 months, 1 year, 1 year after eruption of first tooth, 3 years, 4 years, and 5 years were all recommended) seemed to provoke discussion. According to mothers, there were various reasons why dentists did not want to see young children until a certain age:

"I spoke to my own dentist and he will not even see them until they are in school as "kids that young will not sit still ... "--he doesn't do pediatric dentistry." (Cavity 81)

"My dentist said 4 years old is when they should see them for the first time." (Cavity 81, comment 8)

"My dentist told me that the first appointment was at 3 years old ... And that even then it's not really mandatory but more to get them used to it." (Dentist 26, comment 2)

Even among dental hygienists who participated as parents in the forums, recommendations differed, with one suggesting 2-3 years of age for a "happy visit", and another suggesting 1 year of age to get the baby accustomed to the dental office and to make certain that there was no decay. Nevertheless, mothers seemed to accept that variation around the age of their child's first visit made sense in light of reasons health professionals presented (i.e., to get accustomed to the office or the inability of very young children to sit still through any type of dental appointment), with one mother explicitly explaining:

"It really depends on who you ask. The early check ups are more to get the child used to having their mouth examined. " (Dentist 3, comment 4)

Similarly, mothers seemed to accept that dentists, like doctors, can hold differing opinions, this time with respect to a discussion about toothbrushing at home, the appropriate amount of toothpaste for young children, and whether to use fluoridated or non-fluoridated toothpaste. Contributors noted as "funny" the differences in practice they perceived but did not appear to be frustrated or upset about the confusion:

"Reading the other comments it's funny how different nurses/ drs tell us different things. But then again "rules" are always changing." (Toothpaste 48, comment 7)

"Funny how different dentists have different opinions ... just like doctors ... " (Toothpaste 71, comment 5)

While the "age at first visit" topic showed little evidence of resistance, the issue of toothpaste generated varied expressions of resistance from many mothers. Specifically, while some mothers resisted the use of fluoride toothpaste for very young children, other mothers bypassed the decision of whether to use fluoridated or non-fluoridated toothpaste altogether, choosing non-commercial alternates, such as homemade toothpastes and oil pulling, both of which were commonly presented as good alternatives to commercial toothpastes. Oil pulling, the practice of swishing oil (most commonly sunflower, sesame or coconut) in one's mouth, is a traditional Indian folk remedy mentioned in Ayurvedic texts, where it is said to cure at least 30 different diseases ranging from headache to diabetes by "detoxifying" the body. (20)

"I have been making my own toothpaste for years. Essentially the 3 ingredients are: baking soda coconut oil salt You could probably omit the salt for kids if you wanted. There are some cute jars at the dollar store. Keep in mind that you could add any flavor of essential oil you like if you don't like coconut." (Toothpaste 65, comment 1)

"You could also brush with water and baking soda. I personally don't do it but my mom swears by it and she's a health nut. It also whitens teeth a bit" (Toothpaste 37, comment 2)

"Coconut oil!" (Toothpaste 4, comment 3)

"Have you tried oil pulling? It helps with tooth pain, sensitivity, and even whitens them in the process!" (Toothpaste 68, comment 3)

Though most contributors seemed to agree that fluoride toothpaste was necessary for their children at a certain age, a vocal minority were very strongly opposed, most often citing health concerns: namely, claims that fluoride is a toxin or neurotoxin. For example, in response to a thread asking whether other mothers were using fluoride or fluoride-free toothpaste on their children, one contributor replied:

"Fluoride is toxic & I personally will make sure non is ingested by my LO [little one]. There are many studies proving that it causes neurological damage to name only one of the many problems it causes. Why not just clean your LO teeth with one of the many natural toothpaste on the market these days & limite the amount of sugar they eat. Google effects of fluoride or anything along those lines before you introduce fluoride to LO. I think you will be shocked. Its good to know what fluoride is really about though, if your interested that is. Dentists are taught to push that stuff & insist its safe, im not buying it!" (Fluoride 2.1, comment 5)

A similar example raises concerns that fluoride affects the pineal gland in the brain. In another example, one mother asked the following:

"hi mamas ? are you guys using toothpaste? If so, which one? Fluoride or not? 'I'm brushing morning and night but without toothpaste and at night I (try to) go in with a cloth to clean his gums but today I read an article that said we should use toothpaste ... " (Toothpaste 1)

And received this response:

"Do NOT use anything containing fluoride. Fluoride is a neurotoxin as well as being toxic to the rest of the body. It calcifys the pineal gland which can lead to hormonal imbalances, as well as a serious spiritual block. If you live somewhere with fluoride in the water, the only way to get rid of it is to use a reverse osmosis filtration system. PLEASE do not allow your baby or yourself to ingest fluoride. It is NOT safe!!!!" (Toothpaste 1, comment 7)

The original poster replied to the previous comment with this:

"Thanks for ur reply/concern. We have a well so there is no fluoride added to our water and SO [significant other] and I use toms toothpaste but im thinking a bit strong for lo [little one]. Also, I'm concerned that iflo doesn't get any fluoride at all it could be bad for his teeth. I know it's very bad for us but I guess it's so far drilled into me that we need it that I'm second guessing myself." (Toothpaste 1, comment 8)

While determining the veracity of forum claims is not the goal of our analysis, this quote highlights the power of forum discussions in potentially changing opinion. The original poster appeared to shift from a neutral stance, to being apologetic for considering using a fluoride toothpaste, likely due to the strongly worded response with several words capitalized, and the suggestion of harmful health effects.

These comments reveal a feature of health information seeking in digital contexts. Mothers in their role as "guardians of health" in the home, may seek content from various online sources, and attempt to collate and distill the information from these sources into appropriate health decision behaviours for their family. In this context, some may be more vulnerable than others to posts that criticize or even attack women for practices that they perceive as harmful or "wrong".

Finally, conversations about breastfeeding at night and its relationship to decay in children were a particular source of debate and confusion, where mothers seemed to rightly struggle with recommendations from health professionals and their own sense of practicality and what is best--preferable and feasible--for their children and their family. One contributor expressed that she was not being listened to by her dentist and therefore asked her question about breastfeeding at night on BabyCenter instead:

"The dentist did say it could be that her enamel didn't form properly on that tooth. He also talked about bottle feeding at night after I had already said a couple times she nurses and there are no bottles, so I didn't really feel I was listened to completely and didn't push any further about the possible causes or get into possible nursing and teeth issues ... I have read conflicting info about nursing and tooth decay. If anyone has any experiences or knowledge to share I would love to hear, thanks." (Cavity 66)

The breastfeeding and decay threads underscored a key conflict for mothers. They wanted to breastfeed their children beyond six months of age and spoke of breastfeeding as "natural" and healthy for children. However, forum mothers discussed at length how or whether breastfeeding could cause tooth decay, pulling from various sources to support their views:

"I took my 3.5 year old to the dentist for the first time recently only to find out that he has like 10 cavities! Ouch. And when I told them that I breastfed they said Ohhhhh that's probably the cause ... They said to not let them stay on the breast after they've had enough to eat and to clean out baby's mouth with water after eating ... Now I've never heard this before so I kinda looked at them like they were crazy. But I'm curious--can Breastfeeding really have something to do with his awful dental health? We breastfed until 18 months." (Breastfeeding and decay 2, original post)

"My sil [sister-in-law] is a dentist and she said absolutely not. Breastfeeding does not cause tooth decay. " (Breastfeeding and decay 2, comment 4)

"Oh ya, totally. LO [little one] got 4 teeth at 4 months and now has 12-16 at 17 months! The top 4 teeth look like they might need to be capped. It really bothers me that something so important can also cause so much damage to little teeth. I feel like I've done something wrong to let her teeth be affected like this." (Breastfeeding and decay 2, comment 5)

Other mothers in this thread posted links to news articles, blogs and research to support their claim that breastfeeding did not cause tooth decay.

Within this theme, the topics of children's first dental visit, toothpastes and toothbrushing, and breastfeeding as it relates to tooth decay illustrate the alignment and resistance that are, in Nettleton's (1,2) view, expressions of Foucauldian power. Though at times many mothers seem to highlight disconnect between professional ("expert") recommendations and the contexts of their family lives, we also observed tension between mothers on the site.

Theme 2: Mothers and child dental health: Gender roles and cultural expectations

While the ways that forum contributors engaged with professional expertise and with each other was explicit and often contentious, other, implicit uses of language and allusions to gendered aspects of parenting served to position mothers as the necessary experts on their child's dental health. Although sharing knowledge and support might be seen as helpful or even empowering to forum participants, the tone and content also appeared to reinforce "traditional" gender roles and cultural expectations with regard to parenting. To this end, it should be noted that the forums we analyzed were an almost entirely mother-dominated space: in the 1053 threads considered, only one contributor identified himself as a father. A few contributors mentioned their significant other helping them with things like teeth brushing, but these comments were few. This reality aligns with other content analyses of parenting forums, in which women/mothers are the dominant participants. (9,10,21,22) There were two main aspects of this theme: 1) feelings of mother guilt and societal expectations, and 2) cultural norms about children having "good teeth".

There were numerous examples of mothers experiencing feelings of moral conflicts and guilt (i.e., the "bad mom") surrounding dental health issues for their children, such as accidental injuries to teeth and dental caries. Several mothers shared their guilt over perceived shortcomings with regards to their child's dental health, when discussing issues such as toothbrushing or sugar consumption:

"... I feel like an awful mom offering her juice [...]. Any advice? I feel like I am setting my LO [little one] up to have a sweet tooth and lots of cavities!" (Cavity 58)

"... crap. I never even thought about brushing his teeth yet! Bad parenting guilt setting in ... " (Toothpaste 2)

Likewise, many mothers seemed to worry about wanting their child to benefit from extended breastfeeding and feeling responsible for ensuring that this practice didn't lead to tooth decay. These expressions of guilt and worry shared by posters seem to reflect the immense pressure and societal expectation on mothers to keep children safe and healthy, and to do everything "right". Other contributors generally met these comments with reassuring and supportive responses, normalizing mothers' worry or guilt, yet not challenging the gendered responsibility for child dental health.

A number of comments also appeared to reference embedded cultural expectations about what constitutes "good teeth" for children, which conveyed that health and appearance are linked. North American culture values "straight white teeth", and likewise, teeth that have a "poor" appearance can be a source of social stigma,23 a view that is perpetuated by commercialized dentistry. Beyond feeling guilt and worry, mothers discussed the appearance of their child's teeth, expressing concern when they did not appear "normal":

"Today I notice that he's chipped both of his front teeth. I feel awful. I feel so guilty. His beautiful smile is broken!" (Dentist 243)

"I'm worried because I see kind of weird lines close to [child's] gums. I don't know if it's just me, but I guess her teeth, though not yellowish, are not as white as I would expect them to be. " (Cavity 63)

It is hard to know whether such comments were due to possible health effects of abnormal-looking teeth, or to the cultural value of "good" teeth; it is probably both. There were instances, however, when words like "beautiful" were used to describe teeth, suggesting the concern was at least partly aesthetic. There is also a corporate domain to the idea of "good" teeth, as "straight white teeth" are strongly promoted within North American contexts, as illustrated by promotion of tooth whitening and orthodontic services and marketing of over-the-counter whitening products, by various parties including but not limited to the dental profession. (23)

Limitations

A potential limitation of our study, and area that warrants further consideration, relates to the perceived uniformity of representation of gender and family in the context of the forum, a phenomenon observed elsewhere. (9) While ascertaining demographic information from online sources can be challenging, the vast majority appeared to be women based on usernames or self-identification as a mother, and most women appeared to be in heterosexual partnerships, either married, or in a current relationship, with no one identifying as single. Of the photos and images posted by forum participants, the vast majority appeared to be white. It is possible that mothers of other racial identities and/or living within other family structures were present, but perhaps did not feel comfortable singling themselves out in such an environment where, as Madge and O'Connor found, "other experiences of race and sexuality are "designed out" by omission". (9) There did not appear to be a way to identify contributor's level of education or income, other than a few posters who were hesitant to get certain dental procedures due to the cost.

This apparent uniformity warrants consideration in terms of who may be excluded from these communities. Further, though many mothers seemed empowered by sharing information and social support online, it is interesting to consider whether the gendered nature of BabyCenter Canada works to reinforce stereotypes of mothering and gender roles.

CONCLUSION

Though several content analyses of online parenting forums exist, to our knowledge, this is the first one that focuses on discussions of dental health for children. Our work provides some insight as to how Nettleton's theoretical claims are still relevant, but that the digital context may have shifted the positioning of mothers' relationship to dentistry. Online forums facilitate new types of interaction and discussion, including active pushback against professional recommendations, and sometimes against peers. Our findings also reveal that, in digital contexts, mothers show resistance by triangulating varied sources of information. That is, in addition to health professional recommendations, they seem to look for research online, share practical experiences with parenting forum peers, bringing all those sources to bear on dental health decisions. Further, our findings provide insight into the gendered aspects of caregiving as reflected in Canadian parenting forums, aspects of mother guilt surrounding dental health concerns, and the way in which these forums reinforce "traditional" gender roles, with mothers as guardians of health.

The most unique aspect of our findings is that parents posting to the BabyCenter Canada forums appeared to be very involved and engaged in dental health topics. Mothers using this site engaged with professional expertise and solicited social supports and advice to make their decisions. Though some of the sources might be based on unreliable science, the observation that parents seek information and support outside the context of professional recommendations and interactions--and sometimes, but importantly not always, expressed frustration and confusion about their communications with providers--speaks to potential opportunities for public health and health promotion to reflect on how and why some efforts to engage with parents have been unsuccessful, and to challenge assumptions that people are not engaged or that they are uninformed. Clearly, when we look at the digital context, we see that parents (mothers) are deeply engaged and concerned about their children's dental health. Going forward, insights from this research provide an entry point for considering changes to practice, respectful dialogue, and development of approaches that connect to these organic, user-driven online spaces.

doi: 10.17269/CJPH.108.5944

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Received: October 28, 2016

Accepted: June 28, 2017

Avery Milne, BHSc (hons), Cynthia A. Weijs, RDH, PhD, Rebecca J. Haines-Saah, PhD, Lindsay McLaren, PhD

Author Affiliations

Department of Community Health Sciences, University of Calgary, Calgary, AB Correspondence: Lindsay McLaren, PhD, Department of Community Health Sciences, University of Calgary, TRW3, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Tel: 403-210-9424, E-mail: lmclaren@ucalgary.ca

Acknowledgements: Lindsay McLaren holds an Applied Public Health Chair funded by the Canadian Institutes of Health Research (Institute of Population & Public Health and Institute of Musculoskeletal Health & Arthritis), the Public Health Agency of Canada, and Alberta Innovates--Health Solutions.

Conflict of Interest: None to declare.

* We encountered much duplication among the content yielded by each search term, which reduced the need for additional terms. For example, the content yielded by a search for "dental" largely duplicated the content yielded through the "dentist" search, and thus was not used.

Caption: Figure 1. Organization of the components of BabyCenter Canada's forum

Caption: Figure 2. Visual depiction of two overlapping themes identified from content analysis of BabyCenter Canada forums Table 1. Top-level and second-level codes applied during coding Dental visits Oral care Prenatal Specific tooth practices concerns concerns Dentist-mother Toothpaste Harm to fetus Lip tie Dentist-child Brushing Teeth Child's first Night feeding Cavity dental visit Breastfeeding Decay Dentist (any other Fluoride Injury mention of) Diet Grinding Alternative Thumb sucking Baby bottle Teething Flossing