Knowledge, Attitude and Practice of infant Oral Health Among Pediatricians in Pakistan: A Cross-Sectional Study

INTRODUCTION

Oral health (OH) has been described as an integral component of general health, which significantly impacts an individual's eating, talking and social interaction.¹ Many OH related problems begin during infancy and progressively worsen as the children grow. Early detection of OH problems can prevent the di

seases from worsening.²

One of the most significant early OH problems is early childhood caries (ECC). ECC is defined as "the presence of one or more decayed, missing (due to caries) or filled tooth surfaces in any primary tooth in a child under the age of six (REF WHO 2017)."3 ECC is reported as a significant public health issue all over the world. Differing prevalence rates for ECC have been reported in literature, with a 0% reported occurrence in Nigeria to 98% in Cambodia.3,4 The 2015 Global Burden of Diseases study reported primary dentition caries to be the 12th commonest disease in the world.5 The 2017 Global Burden of Disease study reported 530 million children worldwide having primary dentition caries.6 ECC is not only an issue for low income countries but for high income countries as well. The decayed component comprises of 100% of the dmft index as reported in data from Finland, Greece and Japan.⁷

The most important risk factor for ECC is the consumption of sugars primarily through bottled milk and also through other foods and drinks.8 In addition, the unavailability of toothpastes, socioeconomic status, genetic predisposition, enamel hypoplasia, oral microflora and poor maternal and child nutritional status have also been identified as plausible risk factors for ECC.⁹

Not only do children with OH conditions have problems with eating, but they also undergo a considerable amount of pain and discomfort adversely affecting their social well being as well.4,10,11 Also, a considerable number of children are not cooperative to treatment at dental clinics and thus, need to be treated under general anesthesia (GA).12 Furthermore, the economic burden associated with OH problems in children is considerable as well. Canadian reports estimate that in order to treat only one child having ECC, the cost may vary from $700 to $3000.13 In England alone, more than 60,000 children had their teeth extracted due to caries between 2012 and 2013. The overall cost of extracting these teeth was estimated to be £27.6 million.¹⁴ 

These statistics suggest that OH condition in infants is an important public health problem globally. Evidence suggests that these OH problems can be prevented through the maintenance of good oral hygiene maintenance practice supplemented by healthy eating practice. The concerning problem is that generally parents do not take their infants to a dentist for a routine checkup. Infant visits to a pediatrician or a general physician, on the other hand are usually a regular practice.15 As a result, the first point of healthcare contact for children is a pediatrician, and not a dentist, even for OH related problems making pediatrician's role in maintaining the OH of children, crucial.7 Therefore, evidence-based guidelines recommend that pediatricians should provide dental and dietary guidance including preventive information; early detection, early caries risk assessment, and appropriate referrals to parents and their children so as to prevent the occurrence of OH diseases to help in child's growth and development.¹⁶

Early intervention will provide a chance to educate parents about significant oral health issues, such as prevention of dental caries, preventing dental trauma and appropriate eating practices.17 There is paucity of literature regarding the knowledge, attitude and practice (KAP) of pediatricians regarding infant oral health. Moreover, no study has been reported for assessing the KAP of infant oral health among pediatricians in Pakistan. This study aimed to assess the knowledge, attitudes and practice of infant oral health among a cohort of pediatricians in Pakistan, the precise knowledge and attitude of which can enhance or impede the implementation and eventual success of an oral health related preventive program.

METHODOLOGY

A cross-sectional questionnaire-based study was conducted. A validated questionnaire was used for the purpose of this study. The questionnaire was comprised of two sections. The first section was comprised of a total of 19 questions regarding the KAP of pediatricians about infant oral health. The second section included demographic (age and gender) and practice-related details of the pediatricians.

OpenEpi was used for sample size estimation. Considering a confidence level of 80% for a population of 5000 pediatricians, with an expected frequency outcome of 43.8 + 5%,18 and a confidence limit of 5%, a sample of 157 was considered to be sufficient.

For the purpose of our study, those pediatricians who were registered with Pakistan Medical Council were included whereas, the pediatricians, who were retired, or were not practicing in Pakistan were excluded from the study. Nonprobability convenience sampling was used for recruiting participants. The questionnaire was sent to pediatricians all over the country through Google forms after taking institution's ethical approval.

The responses for the KAP questions were recorded on a five-point Likert scale as 'Strongly Disagree', 'Disagree', 'Neutral', 'Agree' and 'Strongly Agree'. Data was entered and analyzed using SPSS v26.0. At the data analysis stage, these responses were dichotomized as follows 'Strongly Disagree', 'Disagree' and 'Neutral' responses were placed under the 'Disagree' category while 'Agree' and 'Strongly Agree' responses were categorized as 'Agree'.

Frequencies and percentages were described for categorial variables such as gender, experience, attitude, and practice of the pediatricians. Out of the 12 knowledge questions, nine were evidence-based knowledge (EBK), while three were practice-based knowledge (PBK) questions. Mean and standard deviation were described for quantitative variables such as age and knowledge scores of pediatricians. Independent sample T test was applied to compare the EBK scores between pediatricians who had received any kind of training in oral health promotion and those who had not received any training. A p value of less than 0.05 was considered to be statistically significant.

RESULTS

A total of 74 pediatricians participated in the study. There were 35 (47.3%) males and 39 (52.7%) females. The majority of the participants were in the 20-30 (n = 33, 44.6%) and 31-40 years (n = 33, 44.6%) age groups. Only eight (10.8%) participants were of 41 years of age or above.

Thirty-three (44.6%) participants had less than five years of experience, while 26 (35.1%) pediatricians had between 5-10 years of experience. Nine (12.2%) participants reported having between 11 and 20 years of experience, with only five (6.8%) having more than 20 years of experience. The majority of the participants reported working in government hospitals (n = 49, 66.2%). Also, most of the participants worked in urban settings (n = 65, 87.8%).

Most of the pediatricians (n = 40, 54.1%) examined more than 25 patients a day. A total of 29 (39.7%) participants reported seeing 1-5 children with ECC every day, while 16 (21.9%) pediatricians saw 6-10 children with ECC daily. A significant majority of the pediatricians (n = 59, 79.7%) had received no training in oral health status.

The KAP responses have been illustrated in table II. The participants had a mean EBK score of 4.79 + 2.13 out of a maximum of nine. A mean PBK score of 1.21 + 1.21, out of a maximum of three. Pediatricians who had received any kind of oral health promotion training had a significantly greater mean EBK score (6.2 + 1.7), as compared to those without any training (mean EBK score = 4.43 + 2.1; p = 0.002).

DISCUSSION

This study was designed to determine the KAP of pediatricians regarding infant oral health. Gender distribution was well balanced in our sample. The clear majority of the participants were relatively young with 89.2% (n = 86) of the sample of 40 years of age or younger. Due to the overall young age of the participants , the experience of 79.7% (n = 59) of the sample was less than 11 years. To illustrate this association, a study on 510 European pediatricians with a mean age of 52.82 years, the mean experience of the participants was 23.96 years.1 Furthermore, the majority of the participants were working in a government-based hospital (n = 49, 66.2%). Some of these also had private practices as well. In contrast, only 23% (n = 15) of a cohort of Indian pediatricians worked in government hospitals.17 However, these figures could possibly be due to a low sample size selected in the Indian study (n = 65) In a European cohort of 510 pediatricians, 38.2% worked in government setups.1 The majority of the participants in our study also reported to be practicing medicine in urban areas (n = 65, 87.8%).

The overall attitude of the pediatricians was found to be positive. Seventy-two (97.3%) of the participants considered oral hygiene to be significant in the prevention of dental caries. They also agreed that they have a significant role to play in preventing dental caries and that they should examine the teeth of children as well. Hadjipanayis et al, in a study of pediatricians from 26 European countries reported that 97% (n = 495) of the participants agreed that they have a significant role to play in caries prevention.¹ 

However, these opinions were found to be in contradiction with their practice. Only 44.6% (n = 33) of the pediatricians in our study reported examining children's teeth for the presence of caries on a routine basis. Similarly, in a study assessing the knowledge and practices of Australian pediatricians, Koirala et al. reported that 48.5% (n = 80) of the participants only looked for dental caries in half of the patients.19 Interestingly, 89.2% (n = 58) of a cohort of Indian pediatricians reported examining the primary teeth of their patients.19 Moreover, 78% (n = 400) of European pediatricians reported examining patients for oral health conditions as well.

Most of the participants in our study (n = 49. 66.2%) did however counsel the parents regarding cariogenic food. Similarly, Koirala et al reported that 60.5% (n = 95) of a cohort of Australian pediatricians counseled the parents regarding the ill-effects of cariogenic food.19 Gupta et al. also reported counselling 73.7% (n = 65) of the their patients regarding healthy diet.¹⁷

With regards to the mean knowledge score related to ECC, pediatricians had a generally low knowledge of ECC from a theoretical and practice-based perspective. Most of the pediatricians (n = 52, 71.2%) did not know how to conduct a caries risk assessment. In contrast, 52% of Australian pediatricians in a study by Koirala et al. reported having the knowledge to conduct an oral examination.¹⁹

Furthermore, a significant proportion (n = 33, 44.6%) of the participants in our study also did not encourage parents for a child dental visit by the age of one year. In our study, no difference in EBK and PBK was found between the two genders and different age groups. Similarly, Renad et al found no difference in the pediatrician's knowledge of oral health between male and female participants. A major concern in our study was the low proportion of pediatricians trained in any kind of oral health education and examination (n = 15, 20.3%). Inadequate training in oral health issues has been reported as a significant barrier for pediatricians to actively participate in oral health promotion.20 Interestingly, Slade et el reported that is physicians are trained in oral health promotion, they are highly likely to actively participate in oral health education and prevention of dental diseases.²¹

The European Academy of Pediatric Dentistry recommends that brushing with a fluoridated toothpaste should commence soon after six months of age.22 In our study, 36.5% (n = 27) of the participants were not aware that fluoridated toothpaste may be given to children. Similarly, 36% of European pediatricians were also not aware of this as well.1 As per the American Academy of Pediatric Dentists guidelines, the first examination of a child should take place soon after the first tooth erupts.11 A large proportion of pediatricians (n = 33, 44.6%) did not encourage the parents for an early dental visit. Interestingly, 43% of European pediatricians reported recommending parents to visit a dentist after a child is three years of age.¹⁷

ECC has been reported to be aggressive, severely impacting the oral health of children. In our study, 39.7% (n = 29) of the pediatricians reported seeing more than five children with ECC every day. In comparison, 74% of the pediatricians reported diagnosing one patient of ECC per month in a European cohort.1 Similarly, 47% of Iranian pediatricians reported diagnosing at least one patient every month.23

The higher proportion of the reported ECC patients may be misleading, since a significant majority (n = 59, 79.7%) reported receiving no training in oral health examination. Thus, their diagnosis of ECC may not truly reflect the exact figures. Furthermore, the prevalence of ECC in a developing country such as Pakistan are much higher than those reported for developed countries in Europe. Some variation in results may also be explained by this health inequality. A scoping review by Swift et al. identified lack of training; time limitations; and lack of referral systems as significant barriers in pediatricians' lacking in the knowledge and practice of managing oral diseases in children.24

Alshunaiber et al. reported that 76.7% of Saudi pediatricians reported a need for more training in oral health promotion and caries assessment.25 Since 2007, American pediatricians must be competent in implementing oral health screening and be aware of oral health prevention measures in order to pass American Pediatric Board Certification examinations.18

The findings of our study suggest that the knowledge of pediatricians who have undergone any kind of oral health promotion training is significantly higher than their counterparts without any training (p = 0.002). A number of factors have been identified as significant barriers for pediatricians not taking the recommended care of infants' oral health. First and foremost is the lack of training in oral health promotion and assessment which was identified as the most significant factor. Moreover, lack of time due to clinical commitments was another significant issue. Efforts need to be made to design tailored continuing education programs for qualified pediatricians. An oral health promotion module should also be designed and incorporated within the pediatricians' specialty training program.

One of limitation of the current study could be selection bias due to its sampling design involving a convenience strategy. Also, the sample size was relatively low

CONCLUSION

The results of this study highlight the inadequate knowledge of infant oral health among pediatricians in Pakistan. The results may be used to inform future guidelines regarding incorporating oral health education among pediatric training. Although the pediatricians were aware of their role in the prevention of ECC, their training in oral health promotion and caries assessment was evidently lacking. The current undergraduate and postgraduate Pediatrics curricula in Pakistan should incorporate oral health promotion and caries assessment education. Moreover, Continuing Education courses in these areas should also be arranged for pediatricians.

CONFLICT OF INTEREST

No conflict of interest to declare

REFERENCES

1. Hadjipanayis A, Grossman Z, Del Torso S, Michailidou K, Van Esso D, Cauwels R. Oral health training, knowledge, attitudes and practices of primary care paediatricians: a European survey. Eur J Pediatr. 2018;17:675-81. https://doi.org/10.1007/s00431-018-3108-z
2. Preventive oral health intervention for pediatricians. Pediatrics. 2008;122:1387-94. https://doi.org/10.1542/peds.2008-2577
3. Tinanoff N, Baez RJ, Diaz Guillory C, Donly KJ, Feldens CA, McGrath C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. Int J Paediatr Dent. 2019;29:238-48. https://doi.org/10.1111/ipd.12484
4. Chen KJ, Gao SS, Duangthip D, Lo ECM, Chu CH. Prevalence of early childhood caries among 5-year-old children: A systematic review. J Investig Clin Dent. 2019;10:e12376. https://doi.org/10.1111/jicd.12376
5. 
   
6. 2015 G. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1545-602. https://doi.org/10.1016/S0140-6736(16)31678-6
7. Organization WH. Ending childhood dental caries: WHO implementation manual 2019. Recuperado en: https://apps who int/iris/handle/10665/330643. 2019.
8. Phantumvanit P, Makino Y, Ogawa H, Rugg-Gunn A, Moynihan P, Petersen PE, et al. WHO global consultation on public health intervention against early childhood caries. Community dentistry and oral epidemiology. 2018;46:280-7. https://doi.org/10.1111/cdoe.12362
9. Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA, Soobader MJ, Bramlett MD, et al. Influences on children's oral health: a conceptual model. Pediatrics. 2007;120:e510-20. https://doi.org/10.1542/peds.2006-3084
10. Kirthiga M, Murugan M, Saikia A, Kirubakaran R. Risk Factors for Early Childhood Caries: A Systematic Review and Meta-Analysis of Case Control and Cohort Studies. Pediatr Dent. 2019;41:95-112.
11. Fung H, Wong MC, Lo EC, Chu C. Early childhood caries: a literature review. Oral Hygiene & Health. 2013;1:1-5. 11. Irvine J, Holve S, Krol D, Schroth R. Early childhood caries in Indigenous communities: A joint statement with the American Academy of Pediatrics. Paediatr Child Health. 2011;16:351-64. https://doi.org/10.1093/pch/16.6.351
12. Thomson WM. Public Health Aspects of Paediatric Dental Treatment under General Anaesthetic. Dent J (Basel). 2016;4. https://doi.org/10.3390/dj4020020
13. Tikare S, Eroje AB, Togoo RA, Marzoq SM, Alkhammah SM, Alshahrani MM, et al. Pediatrician's knowledge and practice of early childhood caries and infant oral health in southern Saudi Arabia. J Dent Res Review. 2019;6:44. https://doi.org/10.4103/jdrr.jdrr_45_19
14. Rugg-Gunn A. Getting diet right: dietary advice for health in practice. Dental Nursing. 2015;11:381-4. https://doi.org/10.12968/denn.2015.11.7.381
15. Prakash P, Lawrence HP, Harvey BJ, McIsaac WJ, Limeback H, Leake JL. Early childhood caries and infant oral health: Paediatricians' and family physicians' knowledge, practices and training. Paediatr Child Health. 2006;11:151-7. https://doi.org/10.1093/pch/11.3.151
16. Krol DM. Children's oral health and the role of the pediatrician. Current Opinion in Pediatrics. 2010;22:804-8. https://doi.org/10.1097/MOP.0b013e3283402e3b
17. Gupta SK, Gupta S, Gojanur S, Kour G, Singh K, Rani P. Pediatricians' view on early childhood caries and oral health in a north region of India: A cross-sectional study. J Family Med Prim Care. 2019;8:220-4. https://doi.org/10.4103/jfmpc.jfmpc_201_18
18. Oge OA, Centiner, S. Paediatricians' knowledge, attitude and practice towards children's oeal health in North Cyprus. Eurasia J Math, Sci Tech Education. 2017;13:7905-12. https://doi.org/10.12973/ejmste/80723
19. Koirala A, O'Connor E, Widmer R, Kilpatrick N, Goldfeld S. Oral health care: The experience of Australian paediatricians. J Paediatr Child Health. 2019;55:1374-80. https://doi.org/10.1111/jpc.14426
20. Lewis CW, Boulter S, Keels MA, Krol DM, Mouradian WE, O'Connor KG, et al. Oral health and pediatricians: results of a national survey. Acad Pediatr. 2009;9:457-61. https://doi.org/10.1016/j.acap.2009.09.016
21. Slade G, Rozier R, Zeldin L, McKaig R, Haupt K. Effect of continuing education on physicians' provision of dental procedures. J Dent Res. 2004;83(Special Issue A):A1324.
22. Toumba KJ, Twetman S, Splieth C, Parnell C, van Loveren C, Lygidakis N. Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document. Eur Arch Paediatr Dent. 2019;20:507-16. https://doi.org/10.1007/s40368-019-00464-2
23. Bozorgmehr E, Malek Mohammadi T, Hajizamani A, Vahidi A, Khajoee F. Knowledge, attitude, and practices of pediatricians about children's oral health. Journal of Oral Health and Oral Epidemiology. 2012;1:93-8. https://doi.org/10.1155/2013/741783
24. Dickson-Swift V, Kenny A, Gussy M, McCarthy C, BracksleyO'Grady S. The knowledge and practice of pediatricians in children's oral health: a scoping review. BMC Oral Health. 2020;20:211. https://doi.org/10.1186/s12903-020-01198-0
25. Alshunaiber R, Alzaid H, Meaigel S, Aldeeri A, Adlan A. Early childhood caries and infant's oral health; pediatricians' and family physicians' practice, knowledge and attitude in Riyadh city, Saudi Arabia. Saudi Dent J. 2019;31(Suppl):S96-s105. https://doi.org/10.1016/j.sdentj.2019.01.006