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Perceptions of Oral Health Training and Attitudes Toward Performing Oral Health Screenings Among Graduating Pediatric Residents

^a Division of Health Services Research, American Academy of Pediatrics, Elk Grove Village, Illinois
^b Department of Pediatrics, University of Toledo, Toledo, Ohio
^c New Hampshire Dartmouth Family Medicine Residency Program, Concord, New Hampshire
^d Pediatric Dentistry, Duke University, Durham, North Carolina
^e Dorchester House Multi-Service Center, Dorchester, Massachusetts

	ABSTRACT

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BACKGROUND. There is a lack of access to oral health services for American children. Some propose that pediatricians be trained to deliver preventive screening and education to families until they access a dental home. However, little is known about the current oral health training provided during pediatric residency.

OBJECTIVE. The purpose of this work was to evaluate the oral health training that pediatricians receive during residency and their attitudes toward performing basic oral health screenings.

METHODS. The American Academy of Pediatrics Survey of Graduating Residents is an annual, randomly sampled national survey of graduating pediatric residents. The 2006 Survey of Graduating Residents surveyed 611 residents and examined their perception of their oral health training and their attitudes about performing oral health screenings.

RESULTS. Thirty-five percent of residents received no oral health training during residency. Of those who did, 73% had <3 hours of training, and only 14% had clinical observation time with a dentist. Seventy-one percent felt that they had too little oral health training, and only 21% felt that their residency was very good or excellent in preparing them to perform oral health-risk assessments. Residents felt confident in their ability to offer anticipatory guidance but not to do the more technical oral health screenings. The majority of residents believed that pediatricians should conduct basic oral health screenings. Multiple regression analysis indicated that residents who received 3 hours of oral health training, who applied for jobs in the inner city, and whose career goal was to work in primary practice are those most likely to support this idea.

CONCLUSIONS. Pediatric residents currently receive little training in oral health, and the majority wish for more. This study shows that oral health training during residency can increase pediatrician confidence in participating in important oral health promotion tasks, including anticipatory guidance, oral screenings, and oral health-risk assessment.

Key Words: oral health • pediatric residents • primary care • resident education/training • screening

Abbreviations: AAP—American Academy of Pediatrics • ADA—American Dental Association

Dental caries is the most prevalent unmet health need among American children and the most common childhood disease, 5 times more common than asthma.¹ Rates of dental caries are especially high among children living in families with incomes below the poverty level,² and among Mexican American, black, and Native American children.^3–5 Those at highest risk for dental problems are also the least likely to receive preventive dental care.^3,6

Healthy People 2010 lists as 2 of its goals to "reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth" and to "reduce the proportion of children, adolescents and adults with untreated dental decay."⁷ There has been some movement toward this goal with the proportion of 15-year-olds with dental caries and with untreated tooth decay declining between 1988–1994 and 1999–2002 and reaching 40% of the change targeted by 2010.⁸ However, studies have found that the proportion of children aged 2 to 4 years⁸ or 2 to 5 years⁹ years with dental caries has increased during the same period.

A 2003 American Academy of Pediatrics (AAP) policy statement suggested basic preventive strategies that pediatricians can do to lessen the rate of dental caries, including a pediatrician-conducted oral health assessment of both parents and children by the age of 6 months. The policy statement also advised pediatricians to be aware of the infectious pathophysiology and associated risk factors of early childhood dental caries to make appropriate decisions regarding timely and effective intervention and recommended that children should have their first dental visit by their first birthday. Gathering information about the oral health status of the mother is also encouraged because of the evidence of transmission of cariogenic bacteria from mother to child.¹⁰

Earlier studies have found that practicing pediatricians are in favor of playing a greater role in the promotion of oral health, despite a perceived lack of training in this area.^11–13 Regardless of assumptions about dental capacity, models of the impact of implementation of a policy in which pediatricians would receive training in caries risk assessment, screen toddlers, and refer at-risk children to dentists suggest that such a policy would decrease the burden of untreated dental disease.¹⁴

The objectives for this study were to examine several aspects of oral health education during pediatric residency, including the amount of oral health instruction received, training in performing oral screenings, and ability to perform a screening for oral disease risk. Are residents receiving oral health training, and, if so, how much? Are they satisfied with the amount and quality of the training? Did their residency programs have systems in place to record oral health findings and refer patients to a dentist if necessary? When do they believe children should begin seeing a dentist? How involved should children be in their own oral health care and at what age? How confident are recently graduated pediatric residents in their ability to perform oral health screenings and provide parents with information regarding proper oral care and oral disease prevention? Do they think that pediatricians should do so?

	METHODS

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Data Collection
This study used data from the AAP Survey of Graduating Residents. The annual randomly sampled national survey of graduating categorical pediatric residents from all of the US residency programs was initiated in May 1997.

In 2006, 1000 graduating residents were contacted 4 times by e-mail and 4 times by the US Postal Service, for a total of 8 contacts. The response rate was 61.1% (611 of 1000). Female residents were significantly more likely to respond than male residents (66% vs 51%; P < .001). The 2006 Survey of Graduating Residents was approved by the AAP Institutional Review Board.

The survey includes a set of core questions that are the same every year and cover resident demographics, training experiences, satisfaction with training, career intentions, job search, and new postresidency job. There is also a special topic covered every year, and in 2006 the topic was oral health training and attitudes.

Measures
Two questions addressed the amount and quality of residents’ graduate oral health training. The first asked, "During your residency, did you receive any training on oral health care?" Those who had received training then specified "how much/what kind?" by checking all that applied: "<3 hours of seminar/lecture/grand rounds," "3 hours of seminar/lecture/grand rounds," and "clinical observation time with a dentist as part of your residency."

Satisfaction with training was measured with the question, "Was the amount of training time devoted to oral health care appropriate?" and the 3 answer options "too much," "just right," and "too little." Residents also rated their residencies on a 5-point Likert scale (1 = poor, 5 = excellent) in terms of how well their residencies prepared them for several activities, including oral health-risk assessment.

Oral health reporting systems in the residency program were measured with 2 questions: "During your residency, did your physical examination documentation have a space for you to include information about the teeth?" (yes/no) and "Did your residency program have a system in place for referring patients for dental care?" (yes/no).

To ascertain their awareness of or agreement with the AAP recommendation, residents were asked "At what age do you believe children should have their first dental visit?" Expectations for children's ability to take responsibility for their own oral health was examined by asking "At what age do you believe children are able to brush their teeth without help from an adult?" and "At what age do you believe children should be included in discussions of their own oral health?" The American Dental Association (ADA) advises that "most children will be able to brush on their own by the age of 6 or 7 years,"¹⁵ but that the brushing should be done "with supervision until about age 10 or 11, to make sure they are doing a thorough job."¹⁶ All 3 of these questions required fill-in-the-blank answers.

Residents were shown a list of 7 oral health tasks/assessments: (1) inform patients and parents on the oral health effects of sleeping with a bottle; (2) inform patients and parents on the oral health effects of juice and carbonated beverages; (3) inform patients and parents on how to brush correctly; (4) identify teeth with cavities; (5) identify plaque; (6) identify enamel demineralization; and (7) assess parents’ oral health, and they were then asked 2 questions. The first question measured residents’ perceptions of confidence in performing these tasks asking, "How would you rate your ability to perform the following?" on a 5-point (1 = poor, 5 = excellent) Lickert scale. The second question measured their support for the idea of pediatricians performing these tasks, asking "Do you believe pediatricians should perform the following?" (yes/no).

Analyses
Frequencies or means were computed for relevant survey questions. One-way analyses of variance and posthoc Scheffe tests were used to examine specific relationships between continuous variables.

A multivariate linear regression model was developed to explain which characteristics of residents were independently correlated with support for the idea of pediatricians conducting oral health screenings. The dependent variable was a 6-item scale ( = .84) of attitudes about pediatricians’ roles in oral health assessment. The scale was composed of the sum of responses (yes = 1, no = 0) to the first 6 of the 7 oral health tasks and assessments listed above. A factor analysis indicated that "assess parents’ oral health" should not be included in the scale.

Candidate independent variables included in the regression model were female gender (yes/no), age (continuous), residency program size (continuous), international medical graduate (medical degree received outside the United States or Canada; yes/no), whether the resident had received a relatively high amount (3 hours) of oral health training during residency (yes/no), whether the resident had applied for jobs in the inner city (yes/no), and whether the resident's career goal was to work in primary care practice (yes/no). These characteristics were chosen for potential inclusion in the model because they provided a demographic profile of residents, because they are specific to oral health, because they have been shown previously to be associated with a greater likelihood of treating children from underserved populations,^17,18 or because they have been shown previously to be associated with the diversity of patients seen during residency.¹⁹ All of the candidate predictors were screened univariately, and those with P values >.10 were not included in the multivariate model.

The number of responses for each analysis varied slightly based on the number of missing responses for each variable. A P value of .05 was considered significant.

	RESULTS

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Demographics
Table 1 lists the demographic characteristics of the respondents. Among the 611 survey respondents, 74% were women, 63% were white non-Hispanic, 7% were Hispanic, 5% were black, 21% were Asian or Pacific Islander, and 5% were "other." Twenty-two percent were international medical graduates (outside the United States or Canada), 68% were married or living with a partner, and among 23% of those married or partnered the spouse or partner was also a physician. One third had children.

When asked about several areas of training, residents felt least skilled in the area of oral health-risk assessment, in which only 21% said that their training was very good or excellent (Fig 1). This compares with much higher levels of satisfaction in other areas, such as pediatric fellowship training (73% very good or excellent) and using information technology (58% very good or excellent).

View larger version (10K): [in this window] [in a new window]   FIGURE 1 Satisfaction with oral health risk assessment preparation during residency compared with preparation for other activities. Survey question: "Overall, how would you rate your residency in preparing you for each of the following activities?"

View larger version (7K): [in this window] [in a new window]   FIGURE 2 Self-confidence in performing oral health assessment tasks. Survey question: "For the following oral health assessments/tasks, how would you rate your ability to perform?"

The ADA recommends that parents help their children with brushing until the age of 6 or 7 years¹⁵ and that they supervise brushing until the age of 10 or 11.¹⁶ For the questions "At what age do you believe children are able to brush their teeth without help from an adult?" and "At what age do you believe children should be included in discussions of their own oral health?" responses ranged from ages 1 to 11 years. The average response for brushing teeth without help was 4.58 years (median: 4.50; SD: 1.51), and the average response for inclusion in discussion of their own oral health was 3.71 years (median: 3.00; SD: 1.77). Residents who had 3 hours of oral health training during residency, however, had beliefs that were significantly different from the rest of the respondents. Compared with those with less or no training in oral health, residents with more oral health training thought that children should be older to be able to brush their teeth without supervision (0.6 years/7.0 months older age, or 5.08 vs 4.48 years; P = .001). Conversely, pediatric residents with more oral health training thought that children should be included in discussions of their own oral health at a younger age, with the same difference of 0.6 years or 7.0 months (3.37 vs 4.01 years; P = .002).

Oral Health Attitudes
Nearly all (99%) of the residents agreed that pediatricians should inform parents of the negative effects of sleeping with a bottle and of juice and carbonated beverages (Fig 3). Two thirds supported pediatricians doing more difficult assessment tasks like identifying enamel demineralization (67%) and identifying plaque (64%). Only one third (36%) of residents thought that pediatricians should assess parents’ oral health.

View larger version (9K): [in this window] [in a new window]   FIGURE 3 Graduating pediatric residents support the idea of pediatricians performing most oral health assessment tasks. Survey question: "Do you believe pediatricians should perform the following?"

	DISCUSSION

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This study finds that, overall, graduating pediatric residents are aware of oral health problems facing many of their patients, and, although they generally support the idea of pediatricians conducting oral health screenings, many feel that they lack the knowledge and technical skills to do so. Residents tend to be most in favor of conducting anticipatory oral health guidance tasks, such as informing parents of the effects of sleeping with a bottle or the effects of juice and carbonated beverages and are less in favor of doing the tasks that require greater technical training in oral health. Pediatric residents feel the least comfortable in discussing or assessing parents’ oral health, with only one third of the residents surveyed thinking that pediatrician should do so. This finding could be explained by pediatricians feeling uncomfortable discussing what may be perceived as personal parental health issues. A parallel can be drawn here with the results of an earlier study that describes the hesitancy expressed by primary care physicians in regard to assessing mothers for depression.²⁰ Nonetheless, the parental oral health status has an important effect on children's oral health as much as maternal depression impacts her children's well-being. Therefore, as in the case of targeted questions to screen for maternal depression,²¹ developing a quick and effective way to screen parental oral health could produce the same positive results in identifying children at higher risk for early oral disease and implementing the appropriate interventions.¹⁰

The lack of support among some residents for performing more sophisticated oral health tasks, like identifying plaque and enamel demineralization, may be because of a lack of confidence in their ability to do so. Previous studies have found that pediatricians who feel greater self-confidence in a task are more likely to perform it.^22,23 This study confirms this by showing that oral health training can have a significant positive impact in a pediatric resident's confidence in performing more advanced oral health tasks. Previous studies have also shown that it is possible to train pediatricians to recognize and refer children who have dental disease.²⁴

Residents with adequate oral health training were also more aware of children's limitations in taking responsibility for their own oral health. Most children will need help with brushing until they are 6 or 7 years of age.¹⁵ Those with little or no oral health training were more likely to think children could handle this task alone at a younger age. These residents were also more confident in their ability to perform oral health screenings, and the improvement was greatest for the more difficult tasks of identifying cavities, plaque, and enamel demineralization and in assessing parents’ oral health. As a result, these residents were also more likely to support the idea of pediatricians conducting oral health screenings.

Another important finding is that residents who received some oral health training reported a more systematic approach to oral health overall in their residency program, with a greater likelihood of having space to include information about the teeth on their physical examination documentation and of having a system in place for referring patients for dental care. This systematization of documentation and the existence of a referral process can help make follow-up on the disease and collaboration with dental colleagues more likely. This is similar to what pediatricians do for all of the other chronic diseases in childhood (documentation, referral, and follow-up) and makes coordination of care and monitoring of disease status a standard of care. Encouraging and systematizing the same level of documentation and follow-up for this chronic disease of childhood during residency may lead to similar habits in practice.

These findings suggest that adequate oral health training during pediatric residency has the potential to impact the children at greatest risk for oral health problems who might not have access to a dental home. It could also benefit the youngest pediatric patients age 0 to 3 years who have not seen oral health improvements in recent years using current strategies.

However, other barriers to pediatrician-conducted oral health screenings remain. Three of the most important are time, money, and referral sources. As the number of topics to be covered in a well-child visit continues to increase and the time available to cover them, at best, stays the same, decisions on what is important to address must be made. Often, oral health is not on the top of the list of important topics for both the parent and the pediatrician. Yet, dental disease is a preventable disease that can have significant morbidity. Therefore, when, how, and by whom should oral health be addressed in the current environment of pediatric well-child care? In addition, Medicaid reimbursements for physician-conducted oral health screenings vary across states from full reimbursement to partial reimbursement to none at all. In some of the states that do offer reimbursements, the regulations are complicated and present challenges to coding to allow "medical dollars" to pay for a dental service.

Finally, even with the knowledge and skills for screening, recognizing, and providing education and perhaps some intervention for dental disease, pediatricians must connect children with a dental home. Unfortunately, with the dental workforce decreasing,²⁵ general dentists uncomfortable treating very young children,²⁶ limited pediatric dentist availability in many areas of the country,²⁷ and difficulties finding dentists who are willing to accept children on Medicaid,²⁶ the ability of pediatricians to follow the age-1 policy is difficult, if not impossible, in many areas of the country.

	LIMITATIONS

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There are several limitations to this study. All of the findings were based on resident perceptions and self-report. The measurement for the amount of training received was presented to respondents as 3 categories: none, <3 hours of seminar/lecture/grand rounds, and 3 hours of seminar/lecture/grand rounds rather than an open-ended question, so the data do not indicate the exact training time that those with <3 hours or 3 hours had. The scale used in this study has not been validated previously.

	CONCLUSIONS

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Most graduating pediatric residents believe that they should be conducting oral health-risk assessments and screening but feel that they lack the skills to do so because of the lack or limited amount of oral health training received during residency. Although there are already many demands on residents’ time, this study suggests that oral health training can have a large impact on the confidence that pediatricians feel in their ability to participate in oral health promotion tasks.

	ACKNOWLEDGMENTS

 
This study was supported by the AAP.

We thank Wendy Nelson, BA, ACCE, for assistance with oral health policy issues and Elizabeth Goodman, MD, Lynn M. Olson, PhD, and William L. Cull, PhD, for helpful suggestions on an earlier version of this article.

	FOOTNOTES

 
Accepted Mar 26, 2008.

Address correspondence to Gretchen Caspary, PhD, American Academy of Pediatrics, Division of Health Services Research, 141 Northwest Point Blvd, Elk Grove Village, IL 60007. E-mail: gcaspary{at}aap.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

This work was presented in part at the annual meetings of the Pediatric Academic Societies, May 5, 2007, Toronto, Ontario, Canada; the Academy Health, June 4, 2007, Orlando, FL; and the American Public Health Association, November 7, 2007, Washington, DC.

What's Known on This Subject Dental caries is the most prevalent unmet health need among American children and the most common childhood disease. Those at highest risk for dental problems are also the least likely to receive preventive dental care.

 

What This Study Adds We examined several aspects of oral health education during pediatric residency, including the amount of oral health instruction received, training in performing oral screenings, and ability to perform a screening for oral disease risk.

 

	REFERENCES

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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Google Scholar Articles by Caspary, G. Articles by Romano-Clarke, G. PubMed PubMed Citation Articles by Caspary, G. Articles by Romano-Clarke, G. Related Collections Dentistry & Otolaryngology

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