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

Disclosures

BMC Oral Health. 2020;20(211) 

In This Article

Discussion

This is the first review to map and synthesize the evidence on the knowledge and practice of pediatricians regarding children's oral health. Our purpose was to identify all available studies without excluding studies based on study design or quality. Consistent with scoping review methodology, our purpose was not to provide a detailed meta-synthesis or meta-analysis of study findings, rather, to broadly scope the literature, provide a synthesis of key findings, and recommendations for further research.[22] Scoping reviews are intrinsically different to systematic reviews. The goal of a systematic review is to identify and synthesise studies, with a strong emphasis on quality appraisal. They commonly include meta-analysis, where data from studies with a high level of evidence, such as randomized controlled trials, are pooled to identify common effect.[73] By using a scoping review methodology, we did not exclude studies based on quality, rather provided a broad synthesis of the field as a useful starting point to inform future systematic reviews and other research efforts.[22,23] Documenting all relevant studies on the knowledge and practice of pediatricians regarding children's oral health is a strength of this review.

Most of the studies included in this review were cross-sectional and used self-reported surveys to evaluate pediatrician's knowledge and practice. Only two of the reviewed studies used observational designs. While self-reported surveys of knowledge and practice are useful, self-reports of practice may differ from actual practice. Studies that include observation of actual practice and audits of client records would advance knowledge in this field.

A total of 35 (89%) of the studies used researcher developed surveys to explore oral health knowledge and practice. Sample sizes varied across these studies, and few included power calculations. The development of a well-designed, validated tool to assess pediatrician's oral health knowledge and practice is an important first step. In some studies, surveys were based on the American Academy of Pediatrics (AAP) guidelines for caries-risk assessment and anticipatory guidance for infants and young children.[48] Using established guidelines in survey development would appear to be logical, however, gaining international consensus on a consistent tool would enable pooling of evidence and within country and cross-country comparisons. Techniques to build consensus could include international surveys, workshops at international conferences, and the use of the Delphi technique.[74] Validation and testing across different countries would be integral. There was a paucity of qualitative or mixed method studies. Incorporating qualitative methods would be a useful addition to the evidence in this field, to add depth to understandings, particularly in the exploration of barriers to incorporating oral health in pediatric practice.

There was agreement across all studies that there is a role for pediatricians in the promotion of oral health. However, review findings suggest major gaps in oral health education and training. A review of pediatric educational programs should be conducted with oral health content and competencies mapped. In this review, key knowledge deficits were identified in the transmission of bacteria from mother to child in the etiology of dental caries, the clinical signs of early (and therefore reversible) dental caries, and the use of specific interventions such as fluoride therapies. Collectively, the included studies indicate a need for greater formal education and training for pediatricians in oral health and effective interventions. There is a large body of literature that indicates that increased knowledge leads to higher levels of confidence but not necessarily to changes in practice.[2,7–9,36,37,44,50,60–62,66,70,75,76] This may indicate that other structural or setting-based barriers exist but apart from time-constraints none of the authors explored this in any meaningful way. Future studies are needed to provide more a more detailed understanding of the key barriers to translation of oral health knowledge to pediatric practice.

While a number of studies reviewed focused on pediatric practice, there is clearly a need for further studies in this field. Across the studies, there was agreement that oral health screening should be a role for pediatricians, however, there was wide variation in reported rates of oral health assessment. While current guidelines advocate the first dental visit by 1 year of age[48] a lack of awareness of these guidelines and a lack of appropriate referrals was commonly reported. In a number of the studies reviewed, knowledge of fluoride use was explored. Fluoride varnish application for the prevention of carious lesions is supported by evidence,[77] yet lack of confidence and low rates fluoride of use were reported. Robust studies that further explore oral health assessment and utilization of interventions such as fluoride varnish are warranted.

The current and potential practice of pediatricians was a particular focus of this review.

There is some evidence of risk-based referral in some of the studies. This may be appropriate assuming risk status of children is being accurately assessed, however, we were unable to determine this from the study reports. The presence of established irreversible disease (i.e. cavitation) was likely the trigger in many cases for referral rather than an actual risk assessment. Although there was limited information reported in these studies, the findings of Long et al.[30] showed that pediatricians were not referring children rated at high risk if they were not yet showing obvious clinical disease. Existing (clinically visible) disease is the best predictor of future disease,[78] but it should not be used as a risk indicator exclusively.[79] Primary prevention of disease cannot be achieved this way and more sensitive and early risk assessment and intervention is required.[5,80]

In studies that investigated whether pediatricians gave oral health advice to parents, most respondents indicated they did. Available time during routine consultations was the most frequently reported barrier. Regardless of setting or funding mechanisms, health professionals are faced with challenges in allocating resources (including time) whilst maximizing health outcomes.[81] The value of time spent on oral health, as opposed to more routine and familiar activities may not be appreciated if evidence-based interventions (and the magnitude of their impact) are poorly understood or if remuneration for oral health is low or non-existent. If oral health is to be incorporated into pediatricians' care, careful thought should be given to how clinicians will be encouraged and supported to do so.

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