Knowledge, attitudes, and practice of general pediatricians and pediatric subspecialists towards oral health in children: a survey in Turkey

1. Introduction

Dental caries is a serious public health concern and remains the most prevalent oral disease worldwide [1]. The Global Burden of Disease Study in 2019 reported that approximately 2 billion people suffer permanent teeth caries, and 520 million children experience primary teeth caries [2]. Early childhood caries (ECC) is defined as the “presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a child at 71 months of age or younger” [3]. ECC poses a significant oral health challenge, particularly within socially disadvantaged communities [4]. Regular dental examinations are crucial to maintaining the oral health of children [5]. Unfortunately, in many countries, most children do not receive regular dental visits [6]. Young children often do not go to the dentist unless they have an urgent need [7]. Chewing, eating, speaking and physical appearance are strongly associated with oral and dental health, making it an integral part of overall health in children. The significance of oral health as a crucial determinant in enhancing the quality of life among the pediatric population is evident [8]. Optimal oral health constitutes a pivotal factor that significantly impacts overall well-being, academic achievements, and forthcoming oral health outcomes in children [9]. The American Academy of Pediatric Dentistry (AAPD) has emphasized the importance of oral health care and preventive education for protecting children from oral diseases [10]. For this purpose, health workers such as general dentists, doctors, nurses and community organizations should be included in these programs [11].

Pediatrics is a specialty of medicine that deals with the development, medical care and treatment of infants and children. In Turkey, general pediatricians are medical doctors who have undergone specialized training in child health and diseases for at least 4 years following their 6-year medical education that constitutes their foundational medical training [12]. Pediatricians perform examination, diagnosis and treatment planning in children by obtaining medical histories. They are the first reliable source for oral health motivation and caries prevention among children. Guidelines encourage primary health care providers to counsel families on oral and dental care [10, 13].

In the past decades, the rapid development of biological sciences has led to the emergence of subspecialties in medicine [14]. Pediatric subspecialists are the only physicians with unique qualifications to treat children with serious and chronic health conditions. Specifically, they provide preventive care, which differs from basic care provided by general pediatricians focused on the common cold, fever and other common illnesses and injuries [15].

It is crucial to increase the role of pediatricians in promoting oral health, especially in patients who lack professional pediatric dentistry services. There is limited information on the difficulties pediatricians face in the oral care of patients, how much they care about providing oral care, and how much they are willing to improve themselves. Therefore, it is necessary to periodically evaluate the behaviors and attitudes of pediatricians regarding oral and dental health and disease prevention [16].

Literature shows several studies on the knowledge, attitude and practice toward oral health in children; however, no study has evaluated the differences between general pediatricians and pediatric subspecialists [17, 18, 19, 20]. Therefore, this study aimed to determine the knowledge, attitudes, and practices of general pediatricians and pediatric subspecialists toward patient oral health in Turkey.

2. Materials and methods

3. Results

4. Discussion

Dental caries remains a prevalent chronic condition among children, with a high incidence rate observed among Turkish children [24]. The World Health Organization (WHO) emphasizes improving oral health worldwide [25]. In many countries, oral health care is not included in primary health care coverage [26]. While intraoral examination is a recommended pediatric practice, pediatricians receive limited training in oral health during their residency [23]. Furthermore, the work pace of pediatricians is often quite intense [27]. Pediatric subspecialists are highly trained to treat children with complex and rare diseases [15]. Both pediatric subspecialists and general pediatricians treat patients within the same age group in pediatrics; however, significant differences can be observed in their patient populations, clinical practices and treatment approaches. There is no known differentiation in knowledge, attitudes and behaviors regarding the oral health of general pediatricians and pediatric subspecialists.

The study used a sample of 487 valid responses. All pediatricians (100%) agreed that they had a role in promoting oral hygiene habits in patients. However, only half of them (51.4%) reported “often” or “always” conducting oral and dental examinations during routine patient check-ups. The results of the present study are consistent with those of Lewis et al. [23], who said that 90% of pediatricians believed they had a role in dental examinations of children, but only 54% reported that they performed dental check-ups in their daily practice. Another study conducted among Turkish pediatricians by Sezer et al. [16] also reported a low percentage (23.3%) of pediatricians performing oral health examinations for children. In contrast, Singhal et al. [28] (81.3%), Soares et al. [29] (92%), and Hadjipanayis (98.8%) [30] reported high percentages of pediatricians performing oral examinations during routine consultations.

Regarding oral hygiene for babies, the American Academy of Pediatric Dentistry recommends oral health examinations within 6 months of the eruption of the first primary tooth but no later than 12 months of age [10]. In the current study, most participants (71.2%) indicated the appropriate timing for a first dental visit. However, Hadjipanayis et al. [30] reported that only 7% of pediatricians recommended a first dental visit for children under 1 year of age. Aburahima et al. [31] found that nearly half of pediatricians (51.4%) correctly identified the appropriate age for a child’s first dental visit. Multiple studies have reported that many pediatricians are unaware of the recommended timing for a child’s first dental visit, with varying levels of knowledge in different studies [16, 20, 22, 32, 33].

In the present study, 68.5% of the pediatric subspecialists and 55.7% of the general pediatricians correctly identified primary and permanent teeth (p = 0.006). The results of the current study align with the findings of another study, which reported that more than 60% of pediatricians have sufficient knowledge regarding the number of primary teeth [32].

The AAPD guideline also recommends initiating toothbrushing from the appearance of the first tooth, performing it twice a day with a toothbrush, and using toothpaste with a fluoride content of 1000 ppm until the age of 6 years [34]. In the present study, the majority of the total sample demonstrated an acceptable level of knowledge regarding the starting time for toothbrushing (80.9%). However, a lower percentage of pediatric subspecialists (74.1%) compared to general pediatricians (84.3%) exhibited this level of knowledge (p = 0.007). Aburahima et al. [31] reported that 47.6% believed the appropriate age to start brushing was after the eruption of primary molars. In contrast to this study, Indira et al. [32] reported that the importance of initiating oral hygiene practices before the first teeth erupted was not common among pediatricians.

Studies show that fluoride is the most important factor in reducing the prevalence of caries [35]. In the present study, 78.6% of pediatric subspecialists and 92.6% of general pediatricians strongly agreed or agreed that “toothpaste is essential for toothbrushing”. Additionally, 78.2% of PSs, 65.4% of GPs, and 73.9% of the entire population declared that babies under 2 years should use fluoridated toothpaste, consistent with the results of another study [19, 36]. In the current study, most participants did not know the correct ppm ratio of toothpaste used in children 2 to 6 years and those above 6 years. Similarly, Goyal et al. [37] reported that very few participants knew the recommended fluoride concentration in toothpaste for children. Sabbagh et al. [33] found that awareness of fluoride among pediatricians was quite limited. The entire population in this study reported that they did not prescribe fluoride supplements. Likewise, Bozorgmehr et al. [38] found that less than 10% of pediatricians prescribed dietary fluoride supplements in their professional practices. In contrast, Wagner et al. [39] reported that 45.9% of pediatricians recommended the simultaneous use of fluoride supplements and fluoride toothpaste in the first three years, and Lochib et al. [40] showed that 26% of pediatricians recommended fluoride supplements for caries prevention. In this study, we believe that the primary reason for pediatricians not recommending systemic fluoride is the current recommendation for topical fluoride applications by dental associations [41].

For many years, Streptococcus mutans (S. mutans) was considered the primary agent responsible for dental caries, with a direct correlation between S. mutans levels in adult caregivers and the prevalence of caries in their children [42]. However, only a few studies have investigated the effects of interventions to prevent the vertical transmission of oral microorganisms on dental caries levels in children, and the results of these studies are subject to debate [43, 44]. Recent genetic and microbiological research on dental caries reveals that S. mutans is only a minor constituent of the bacterial community. Dysbiosis is related to an imbalance in the microbial community within the oral cavity [45]. From the current perspective, dental caries is considered a non-infectious polymicrobial dysbiosis condition caused by low-level pathogens in oral health [46]. In the present study, 75.5% of the participants found the statement “Cariogenic microorganisms can be transmitted from mother to baby” correct (a higher percentage than reported in other studies) [17, 36].

Previous studies have reported that pediatricians were fully aware of the effect of bedtime bottle feeding [16, 32, 33]. In the present study, 72.8% of pediatric subspecialists (PSs) recommend bottle-feeding to their patients, which is higher than the 33.5% recommended by general pediatricians. We believe that the PSs recommend bottle-feeding at a higher rate due to the inability to switch to solid food or the inability to breastfeed due to special conditions or systemic diseases in PS patients.

In the current study, most participants indicated that they work in a university hospital with a high volume of daily patient examinations. Female participants in this study demonstrated more supportive attitudes and a greater depth of knowledge regarding pediatric oral health. Additionally, our findings revealed that pediatric subspecialists possess more extensive knowledge than general pediatricians. However, the study found no significant correlation between GPs and PSs regarding their attitudes toward proper oral hygiene for children. The results of our study underscore a notable discrepancy in knowledge, behaviors, and attitudes between general pediatricians and pediatric subspecialists in the context of pediatric oral health. Notably, we were surprised to discover that years of clinical experience did not correlate with increased knowledge or adoption of correct attitudes during clinical practice. Pediatricians play a crucial role in enhancing family awareness and knowledge of oral health. While basic oral health education for infants and children is part of the pediatric residency curriculum, it is important to ensure that pediatricians not regularly involved in child follow-up are updated through continuing education programs.

The strength of this study lies in its ability to reveal differences in knowledge, attitudes and practices regarding oral health in children among pediatricians who initially specialized in the same field of medicine but later pursued different subspecialties. Additionally, it represents the first comprehensive study with diverse questions. Nevertheless, it is crucial to acknowledge the limitations associated with our research. The convenience sample we employed consisted of individuals who actively sought to update their knowledge, potentially introducing a bias toward participants more motivated to improve their practices. This limitation may restrict the generalizability of the study findings to a broader population of professionals who do not attend such events and may have varying levels of engagement in oral health-related practices. For future research, it is advisable to include a more diverse and representative sample to enhance the external validity of these findings. Moreover, the study results may have been influenced by socially desirable responses, particularly when addressing questions related to participants regarding their oral health issues and dental care for their children.

5. Conclusions

This study identified differences in the knowledge, attitudes, practices, and fluoride approaches between general pediatricians and pediatric specialists toward oral health in children. Pediatric specialists demonstrated higher knowledge levels of oral health in children than general pediatricians. Additionally, the study found that years of experience did not correlate with increased knowledge or adopting proper attitudes toward pediatric oral health.

Availability of data and materials

The data presented in this study are available on reasonable request from the corresponding author.

Author contributions

EAS, EYT and BK—equally designed the research study. EAS, EYT and IHA—equally performed the research. EAS and EYT—analyzed the data. EAS—wrote the manuscript. BK and IHA—provided help and advice on the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This descriptive cross-sectional study was conducted following the guidelines of “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE statement) and reviewed and approved by the Marmara University Ethics Committee (2022-88). Participants received oral and written information about the study as part of the consent process.

Acknowledgment

We thank the pediatricians for their participation and interest in our study.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.