Early childhood caries (ECC) is defined as the “presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child aged 71 months or younger” [1
]. ECC has significant adverse consequences on a child’s health and overall well-being, including increased risk of future caries, hospitalizations, emergency room visits, and missed school days.
ECC is a major public health concern in Taiwan. The prevalence of caries increased with age among Taiwanese preschool children, with a prevalence of 7.08%, 31.4%, 51.55%, 78.05%, and 79.32% among children aged 1–2, 2–3, 3–4, 4–5, and 5–6 years, respectively, in 2011 [2
]. Tsai et al. reported high numbers of untreated caries among children in Taiwan with a mean deft of 0.14 at age 2, 2.58 at age 3, 4.41 at age 4, 6.94 at age 5, and 7.31 at age 6 [3
]. By age 6, 89% of children had caries.
Fluoride varnish has been widely accepted by dental experts as a crucial component of preventive dental health care in preschool children [4
]. Fluoride varnish applied twice a year, along with counseling of the caregiver regarding diet and tooth brushing, has proved to be efficacious in reducing the incidence of dental caries in children [6
]. In 2004, the Taiwan government launched a preventive fluoride varnish program aimed at reducing the disease burden of caries among preschool children. Currently, National Health Insurance (NHI) provides fluoride varnish application to children younger than 6 years with an interval of at least 6 months. The preventive fluoride varnish treatment service is provided only by licensed dental practitioners in dental offices, which are reimbursed by the government for the service.
The preventive services by dentists comprise an oral examination of the child, caries risk assessment, oral health counseling for parents, and application of fluoride varnish. Although over 95% of dentists practicing in various settings are contracted to provide this treatment in Taiwan, since its implementation, most children have not received fluoride varnish. Statistics indicated that only 0.5% to 34% of children aged 0 to 4 were administered fluoride varnish treatment twice a year in 2012 [2
]. The rate of fluoride use was relatively high among children aged 4–5 years (43.3%), whereas younger children had a lower probability of receiving fluoride varnish application [7
]. Among children with disability, up to 9.84% received fluoride varnish treatment, and the use decreased with an increase in the level of disability [8
]. Therefore, an increase in fluoride varnish use for preventing caries among preschool-aged children in Taiwan is necessary.
Primary care physicians and pediatricians establish early relationships with young children and their parents. They frequently examine infants and young children in the early years of life when prevention is critical and lifelong habits are being established. As previously reported, 89% of infants and children aged 1 year had medical office-based physician visits annually, compared with only 1.5% who had dental visits [9
]. Family physicians and pediatricians often examine children up to six times before the age of 2 years; thus, these appointments must be considered opportunities to increase awareness of oral health evaluations, screen young children for caries risk, and refer children to dental care [10
]. Preventive measures initiated during the first years of life can significantly reduce the risk of ECC and the need for expensive restorative procedures later in life. Considering that preschool-aged children are significantly more likely to visit a physician’s office than a dentist’s office and the current need to increase the use of caries prevention services, the interest among pediatricians in Taiwan in incorporating fluoride varnish application for caries prevention into their patients’ medical visits has been increasing in recent years. By acquiring skills for applying preventive strategies and appropriately referring patients to dentists, primary care physicians and pediatricians may help eliminate oral health disparities. However, no research has been conducted to assess the degree to which physicians in Taiwan are knowledgeable in aspects of oral health in children. Moreover, evaluating the current knowledge and practice regarding caries prevention of dentists in Taiwan is necessary, prior to considering the involvement of other health professionals in caries prevention activities. To date, limited literature is available on the knowledge, attitude, and practice (KAP) aspects of caries prevention among dentists in Taiwan [11
The present study analyzed the ECC-related KAP of dentists and pediatricians and identified the pathways through which the knowledge and practice of medical and dental professionals in Taiwan affect their attitude toward medical office-based caries prevention in Taiwan.
Knowledge questions with correct responses were scored 1 and incorrect answers were scored 0. We combined “do not know” responses with incorrect answers and scored them as 0. The sum of all 10 knowledge scores was used to quantitatively describe the knowledge of each participant. For each of the six caries prevention practice activities, the participants from the general and pediatric dentist groups were asked to grade the frequency with which they practice each activity on a scale of 1 to 5, with 1 representing “very rarely” and 5 representing “very often.” For pediatricians, a practice section was designed to grade their willingness to perform preventive activities if those activities are included in their routine practice on a scale of 1 to 5, with 1 representing “very unwilling” and 5 represented “very willing.” The sum of all six practice scores was used to quantitatively describe the practice of the participants. To analyze the distribution of responses to practice questions in the three groups, “often” and “very often” responses and “uncertain,” “rarely,” and “very rarely” responses of dentists were grouped together. In the pediatricians’ version, “willing” and “very willing” responses and “uncertain,” “unwilling,” and “very unwilling” responses were grouped together. Attitude was assessed on three-point scales (“agree” = 1, “uncertain” = 2, and “disagree” = 3) to statements regarding barriers in implementing medical office-based caries prevention. The sum of all 13 attitude scores was used to quantitatively describe the attitude of the participants. Higher scores denoted a more positive attitude toward engaging physicians in preventing caries in medical offices. The maximum possible scores were 10, 30, and 39 for knowledge, practice, and attitude, respectively.
After more than a decade since the Bureau of NHI launched the fluoride varnish application program for children younger than 6 years to prevent ECC, the use of fluoride varnish application among the young population in Taiwan has been increasing each year; however, the rate remains below the desired value. The findings of the present study suggest that pediatric health professionals in medical offices have a relatively positive attitude toward and willingness to practice caries prevention activities if those activities are included in their routine practices. Interestingly, the attitude level among dental professionals regarding the engagement of physicians in medical office-based caries prevention was significantly lower than that of pediatricians. Discordance in attitudes toward physicians’ engagement in caries prevention activities was largely explained by the knowledge level of the participants.
The present study demonstrated an overall lack of oral health knowledge among the pediatricians. More than half of the pediatricians correctly responded to only two knowledge items; specifically, they correctly indicated that having meals in close succession entails a risk of caries (62.9%) and identified the timing of the child’s first dental visit (74.3%). These findings are similar to those in other investigations on pediatricians from Canada, the United States, Iran, Italy, Saudi Arabia, Brazil, and the Netherlands regarding the knowledge of physicians and primary care providers about early childhood caries and infant oral health [16
]. We found that the pediatricians’ knowledge level was positively correlated with their willingness to perform caries prevention practices. However, only 35% of the pediatricians were willing to assess fluoride intake as part of caries prevention for their patients. This finding may be attributed to pediatricians’ insufficient knowledge on fluoride usage for preventing caries.
Our findings indicate that despite the generally low level of knowledge in caries prevention, pediatricians with higher knowledge levels were significantly more likely to possess positive attitudes toward medical office-based caries prevention and be willing to perform caries prevention practices. In the present study, more than half of the pediatricians (58%) agreed that they could apply fluoride varnish to prevent ECC in children. Our findings are in accordance with previous studies that reported a more positive attitude toward pediatricians’ role in preventing oral diseases in pediatricians with a higher level of knowledge. Di Giuseppe et al. described physicians more knowledgeable in oral health as being more likely to play a role in promotion of children’s oral health [18
Oral health care and caries prevention in children should incorporate caries risk assessment, individualized preventive strategies, and anticipatory guidance [12
]. Establishing the periodicity of supervision during care intervals and determining age-appropriate “care paths” are based on the risk of disease in each individual. An infant oral health visit consists of a six-step protocol, comprising caries risk assessment, proper positioning of the child, age-appropriate tooth brushing prophylaxis, oral clinical examination, fluoride varnish treatment, and anticipatory guidance and counseling. For optimal outcomes, caries risk should be assessed as early as possible, and preferably before the onset of the disease process. A lack of knowledge and information regarding caries prevention and preventive interventions prior to fluoride varnish application may cause pediatricians to acknowledge fluoride varnish application as a straightforward activity, which leads them to believe that they can perform it. Furthermore, for those pediatricians who disagreed that they can apply fluoride varnish, a lack of confidence and uncertainty concerning whether oral screening and fluoride varnish application take time were found to be significant factors affecting their perception of applying fluoride varnish. These uncertain responses may be related to the low level of knowledge and lack of training regarding oral health care among pediatricians. Positive associations between physicians’ confidence and their likelihood of performing oral health practices have been identified in the United States [22
]. Lewis et al. reported that although pediatricians clearly support preventive oral health, the most cited barrier to these pediatricians’ further involvement in oral health was the lack of training [13
]. In the present study, only 58% of the pediatricians had some exposure to oral health courses. Another study by Herndon and colleagues demonstrated that oral health training indirectly influences physicians’ pediatric oral health practices by increasing their confidence in activities such as advising parents and performing oral health screening and risk assessment [24
]. Efforts to engage physicians in oral health training will promote physicians’ confidence and increase the likelihood of their performing preventive oral health care practices [25
]. The results of our study indicated a positive association between the knowledge and attitude of pediatricians. Thus, if appropriate education and training are provided, pediatricians will support their role in caries prevention and will be willing to provide caries prevention services. Therefore, efforts are necessary to expose pediatricians in Taiwan to oral health-related education and provide them with training to increase their knowledge and confidence in practicing oral health preventive measures in children if a medical office-based caries prevention program is to be implemented in Taiwan.
The present study demonstrated a good overall knowledge level among general and pediatric dentists in Taiwan. By contrast, the score in attitude toward medical office-based caries prevention was significantly lower in the two groups of dentists than in the pediatricians. The knowledge level of the general dentists had a negative correlation with their attitude toward engaging physicians in providing caries prevention measures to children; however, this correlation was not statistically significant. A majority of the general dentists (65.8%) and pediatric dentists (79.7%) disagreed that physicians can apply fluoride varnish to prevent ECC in children. It appears that when dentists are knowledgeable in aspects of oral health in children and their challenges, they acknowledge its importance more and are likely to practice the preventive activities by themselves; however, they consider other health professionals unable to perform these activities. Dentists are aware of necessary procedures prior to fluoride varnish application, including oral examination and caries risk assessment, and necessary oral hygiene instructions that should be provided afterward to the caregivers of children [26
]. Although the correlation was not statistically significant, it may explain why the general dentists who had higher knowledge levels, had a negative attitude toward whether ECC prevention can be performed by pediatricians. It is expected that the pediatric dentists possessed the highest knowledge and practice levels regarding oral health in children. Thus, the overall low level of attitude among the pediatric dentists was presumably caused by their high knowledge levels. In a previous survey among AAPD members, pediatric dentists responded that the AAPD should focus its efforts on educating pediatricians and primary care physicians regarding the value of early dental evaluations [27
In our study, a translation of knowledge into practice was observed. A previous systemic review demonstrated that dental education and training has emerged as the most important factor affecting dentists’ attitude toward how they conduct their activities [28
]. Dentists who were continuously engaged in their professional and educational development were more open to the new demands of the profession and more likely to include prevention in their daily routine. This finding is consistent with our results regarding general dentists because their caries prevention practice levels were positively correlated with their ECC-related knowledge levels. General dentists with higher knowledge levels and information on children’s oral health performed caries prevention activities frequently in their practice. However, this correlation was not observed among pediatric dentists. We found that pediatric dentists frequently practiced caries prevention measures regardless of their knowledge level.
Although the present study revealed that general and pediatric dentists in Taiwan were knowledgeable overall in aspects of oral health in children, differences in knowledge concerning certain items were observed between dental professionals; specifically, the knowledge level of general dentists regarding fluoride usage in caries prevention was lower. Only 42.7% of the general dentists responded correctly to the knowledge item related to fluoride tablets. Therefore, the knowledge level of general dentists regarding fluoride usage for ECC prevention should be improved and updated according to the current clinical guidelines to acquire consistent knowledge to further enable and encourage them to provide their patients with optimal preventive care. Our study is not the first to indicate gaps in fluoride usage-related knowledge between general and pediatric dentists. A previous study by Narendran et al. demonstrated a knowledge gap between dentists in the aspects of excessive chronic fluoride exposure, the fluoride supplement dosage, and inappropriate prescription practices; thus, they emphasized strengthening educational interventions at the undergraduate and practitioner levels [29
There are a few limitations in this study. First, the study had a small sample size. We could not identify the potential confounding variables may due to the limited sample size. Second, pediatricians’ practice behaviors were self-reported according to the willingness to perform the activities; thus, they might not reflect the actual practice patterns. Third, overall KAP surveys have inherent limitations: for instance, respondents may be primed to provide certain responses, and the multiple-choice format of the questionnaire may direct them to socially desirable answers.
The preventive care policy for applying fluoride varnish in children in Taiwan still requires aggressive promotion, and additional efforts must be made to increase the application of caries prevention interventions among preschool-aged children. Partnerships with other health care professionals for providing preventive care for high-risk populations is crucial to improving oral health outcomes in the future. Caries risk assessment by a pediatrician or family physician and referral of high-risk children to dentists would reduce the disease burden under most plausible scenarios. Pediatricians and dentists must work together to improve the quality of preventive oral health care available to all young children. The findings of this study are expected to contribute to the understanding of dentists’ and physicians’ current knowledge, attitude, and practices regarding oral health in children in Taiwan. The results of this study indicate the need to improve oral health-related knowledge in pediatricians if such medical office-based caries prevention programs are to be implemented in Taiwan. This information may then be used as a useful reference for planning and decision-making for improving the oral health care provided to the younger population in Taiwan.