The Knowledge and Practice of Pediatricians in Children's Oral Health

A Scoping Review

Virginia Dickson-Swift; Amanda Kenny; Mark Gussy; Colleen McCarthy; Stacey Bracksley-O'Grady


BMC Oral Health. 2020;20(211) 

In This Article


The initial search yielded 3174 studies from all databases. After the deletion of duplicates, 2467 results remained. A total of 2071 articles were excluded as non-empirical studies, (many were general policy guidelines), or articles related to general dentists or pediatric dental specialists.

Of the remaining 396 articles selected for title and abstract review, a random selection of 10 was made to assess interrater reliability.[27] Each team member (n = 5) independently reviewed the same 10 articles against inclusion and exclusion criteria. Scorer sheets were completed and Kappa's co-efficient was calculated using Stata™ data analysis software. The kappa-statistic measure of agreement was 0.6190, indicating substantial agreement.[28] Discussion of these 10 articles occurred between all authors which supported the development of shared understandings. To ensure consistency across the review, a decision was made that all abstracts would be reviewed by the same second reviewer (VDS). This process resulted in strong agreement through the review process. Any conflicts between reviewers were discussed by the full team until agreement was reached.

The 396 articles were retrieved and reviewed by five reviewers (approximately 80 per reviewer). A further 322 articles were excluded as not meeting the criteria. The full text of the 74 remaining articles were evaluated by two researchers (VDS, CM). Another 34 studies were excluded: 19 did not focus exclusively on pediatricians, eight were focused on evaluations of training programs, three were reviews, one was an opinion piece, one included interviews with parents, one examined interprofessional practice, and one was a duplicate. Hand searching of the reference lists of the included studies resulted in another two articles being identified, resulting in a total of 42 articles eligible for inclusion in this review. Figure 1 outlines the review process.

Figure 1.

PRISMA flowchart

Key Features of Included Studies

The 42 included studies were mostly undertaken by US and Indian research teams and were published in the latter part of the 2000s: India (11 studies), US (9 studies) Saudi Arabia (3 studies), Brazil, (3 studies), Nigeria (2 studies), and single studies from a range of other countries including UK, Australia, Belgium, Germany, Iran, Singapore, Italy, Taiwan, Montenegro, Lebanon, Trinidad/Tobago, Turkey, Tehran, and one that covered a number of European countries. A total of 39 (92%) used cross-sectional self-reported surveys ranging from 18 to 101 items, via telephone, hard copy, mail and web based. The remaining three studies included two observational studies[29,30] and one qualitative study.[31]

The surveys were often developed by the researchers based on studies conducted in similar countries. For example, the US National Survey developed by Lewis[9] and colleagues was used as a basis for studies in the US[9,32–4] and Australia[35] whilst tools developed for the Indian context[36–39] were frequently adapted for studies in India and the Middle East. Only four studies reported using validated tools.[7–9,34] More than half (51%) of the survey studies provided no detail of the tool validation or pre/pilot testing. The survey tools predominately focused on the domains of knowledge and practice. Knowledge included questions related to age for first dental visit, oral health risk assessments, including caries etiology, risk factor prevention, toothbrushing, and fluoride supplementation. Practice questions included oral health screening and examination, anticipatory guidance, referral to dentists and fluoride application.

Two studies used observational designs to assess pediatrician's ability to identify visible plaque on the teeth of young children[29] and to identify risk for the development of early childhood caries (ECC).[30] A qualitative interview study conducted by Karasz and colleagues[40] explored the barriers and facilitators to caries prevention for young children of immigrant Bangladeshi families in New York.

Whilst many of the studies published between 2000 and 2010 focused on the US and India, studies published in the past 3 years (2017–2020) have been undertaken in 9 new countries (Australia, Brazil, Lebanon, Taiwan, Europe, Saudi Arabia, Singapore, Trinidad/Tobago and Montenegro).

Sample sizes for the included studies ranged from 15 to 862 pediatricians. The qualitative study undertaken by Karansz and colleagues had the smallest sample (15) appropriate for a study of this type. In the survey-based studies (n = 39) half of the sample sizes were relatively small with 19/39 (49%) with samples of 100 or less. A total of 31 % (12/39) had samples between 100 and 300 and 8/39 (20%) studies with samples over 300. The largest sample (n = 862) was in the US national survey in 2000 (response rate of 62%).[9] Most studies did not report on sample sizes relative to the population of pediatricians in each of the areas in which the surveys were carried out.

Synthesis of Study Findings

Munn et al.[22] reinforces the need for authors using scoping review methodology to comprehensively describe the key findings from included studies. The contents of the 42 identified articles were thematically analyzed, and clustered into three groupings: knowledge, practice and barriers.

Oral Health Knowledge

Oral health knowledge of pediatricians was often reported as inadequate. Authors from the US highlighted a lack of knowledge in relation to developmental oral health[33] and age for first dental visit.[34] Lack of knowledge of dental caries was reported from a researcher developed survey of 75 pediatricians in India,[36] and in Saudi Arabia, significant gaps in knowledge regarding the use of pit and fissure sealants and fluoride supplementation was reported from a researcher developed survey of 363 pediatricians. Similar findings were reported in Nigeria,[41] Brazil,[42] Tehran.[43]

Authors of the reviewed studies indicated limited knowledge and understanding of the transmission of bacteria from mother to child in the etiology of dental caries. In a large European study, 22% of respondents reported being unsure about bacterial transmission.[44] Two Indian studies explored pediatrician knowledge of bacteria transmission. In one study,[36] less than half of pediatricians knew that bacteria associated with dental caries could be transmitted from mother to child. In the second,[45] half of respondents disagreed that bacteria associated with dental caries are transmitted from mother to child. Poor knowledge of transmission was reported in other studies.[46,47]

Data from a large European study, using a web-based survey with 510 European pediatricians who were members of EAPRASnet (European Pediatric Research In Ambulatory Setting Network), indicated that 25% of respondents were unaware of the initial clinical signs of dental caries (i.e. early or white spot lesions).[44] From a recent Australian survey adapted from the American Academy of Pediatrics[48] only 17.1% of Australian pediatricians rated their ability to assess dental caries as excellent and only 7.6% felt confident in their ability to assess plaque buildup.[35] A lack of awareness of early lesions was found by Nassif and colleagues[49] in Lebanon, with 25% of pediatrician respondents unaware.

Emmi and colleagues[50] in Brazil used a researcher developed survey of 70 pediatricians with 90% of respondents having outdated knowledge in areas such as fluoride use. In the US, Lewis and colleagues[7] reported that 94% of study respondents were confident in determining the need for fluoride supplementation and providing the right fluoride dose. Whilst in the UK, Kalkani and colleagues[51] found that only one in five pediatric postgraduate trainees could correctly identify the correct dosages for fluoride supplements. In India, a study by Shetty & Dixit[52] found that 92% of pediatricians surveyed knew about fluoride use as a preventative measure, although no data were collected on how many recommended fluoride in their practice. German pediatricians recommended the simultaneous use of fluoride supplements and fluoride toothpaste 45.9% of the time for children in the first 3 years without information about other fluoride sources or water fluoride levels.[53]

Oral Health Practice

There were only two studies that used observational methods to examine pediatrician's ability to assess for early childhood caries.[29,30] Dumas and colleagues[29] assessed pediatricians' ability to identify visible plaque. These results were then compared to an examination undertaken by a dental hygienist. Pediatricians (n = 28) identified visible plaque on 39% of children (n = 118), with low levels of agreement with a dental hygienist. In the US, 1288 pediatricians completed an oral health risk assessment and referral tool (POORT) The results showed low referral rates for at risk children.

From a researcher developed survey[52] of 84 pediatricians in India, only 24% of respondents considered themselves knowledgeable on oral health and reported direct impacts on rates of routine oral health examination. Sezer et al.[54] established a relationship between pediatricians' knowledge and dental referral rates; pediatricians with greater knowledge reporting higher rates of referral.

Studies conducted in the US and India found high levels (~ 80%) of agreement that pediatricians had an important role in identifying dental problems and moderately strong agreement that they should provide counselling on the prevention of dental caries.[9,36,55,56] In a national survey undertaken in the US by Lewis,[7] 90% of pediatricians agreed that they should examine children's teeth for dental caries, but only about half (54%) reported examining the majority of 0–3-year-old children. In countries other than the US, variable rates of examination for oral disease were reported. Rates ranged from 90% in a Canadian study[39] to between 13 and 60% in Indian studies.[38,56,57] In an Indian study,[52] researchers identified practice setting differences, with 65% of pediatricians practicing in both teaching institutions and private practice, but only 32% of those working exclusively in private practice reported screening for dental disease. Selective examination for oral diseases was found by Bozogemehr and colleagues;[58] oral exams were conducted by 88% of their respondents but only if the child had a reported problem. In Australia pediatricians reported undertaking general assessments including chest (71%) and cardiac (77%) examinations, but only 40% routinely conducted oral health assessments.[35]

Karasz[31] reported that while most pediatricians were aware of the guidelines for referral of children to a dentist before 12 months of age, few ensured referral completion. A lack of awareness and implementation of dental referrals for young children was reported across a number of studies.[31,36,44,55,59,60–63] Studies from the US showed wide variations in dental referral rates of one-year-old infants ranging from 8 to 45%.[34,47,60,64] Virdi et al.[56] reported that two-thirds of pediatricians surveyed recommended a dental check-up only when dental problems were reported. Similarly, Indira et al.[62] found that only 11% of pediatricians routinely advised caregivers about the child's first dental visit before age one.

Prescribing of fluoride supplements and/or application of concentrated fluoride varnish (CFV) was variable across the studies. Authors that included reports on the application of CFV, found rates of use were low. Lewis et al.[7] reported that while 20% of pediatricians agreed that they should apply CFV routinely, only 4% of pediatricians did this regularly. There appears to have been only limited increase in CFV application over the past 6 years, with more recent findings from the US indicating 12% of pediatricians apply fluoride varnish treatment to children between three and six.[65] Reported rates of prescribing fluoride supplements showed large variation from nearly 90% of pediatricians surveyed in one study prescribing fluoride supplements in Italy[66] to only 7% in Belgium.[67]

Barriers That Impacted on Oral Health Knowledge and Practice

There was a lack of reporting on the key barriers that impacted on oral health and knowledge and practice with most studies focusing on inadequate education and training opportunities for pediatricians.[7,9,33,36,41,43,51,55,68,69] In a Brazilian study, Balaban et al. 83.4% classified the oral health content in their medical education as either non-existent or deficient.[68] Some authors reported that increased training led to improved pediatrician confidence, and knowledge of dental topics, however, little effect on actual practice was reported.[66,70] Despite this, authors of many of the included studies made recommendations for further training.[7,8,33,41,51,52,71,72]

A major practice barrier was related to time. Lewis[8] found the majority (84%) of respondents in their study provided anticipatory oral health guidance to parents or carers, however, only 39% felt they had adequate time to fully cover all of the guidance they wanted to impart during a visit. In a follow-up study by the same authors, over 90% of pediatricians educated families about preventative oral health.[7]

In the US, one of the persistent barriers to referral was the medical/insurance system.[7–9] Parental acceptance of dental advice and low likelihood of caregivers implementing dental referrals or recommendations were also identified.[31,34] Other barriers identified included costs, long waiting times for dental treatment[64] and lack of dental providers that were willing to see infants and young children.