Abrar Alanzi,Saleh Muhammad,Anfal Faridoun,Aisha Alterkait
Pediatricians' Knowledge of Children's Oral Health: A National Survey
Paediatrics,Oral health,Knowledge,Children
Background A high percentage of dental caries (∼70%) was reported amongst 4- and 5-year-old Kuwaiti kindergarten children. Parents contact paediatricians several times during the child's early life. Paediatricians can play an important role in improving the oral health of their patients. The objective of the study is to evaluate the knowledge level and awareness of paediatricians and paediatric residents regarding children's oral health in Kuwait. Methods A national cross-sectional survey was distributed to paediatricians and paediatric residents practicing in Kuwait. Data concerning demographic variables, knowledge on dental caries preventive measures, current anticipatory guidance, and experience with dental problems and oral care were collected using online and paper-based surveys. Results A total of 230 participants completed the survey, with a response rate of 50.1%. Most respondents (81%) had frequently noticed dental caries in children in their practice. Two-thirds of respondents felt confident in detecting dental caries. However, more than two-thirds were unfamiliar with preventive dental practices and the management of dental trauma. Only 16.5% of the respondents got a satisfactory knowledge score on the preventive measure questions, and nearly 51% had satisfactory knowledge on the recent anticipatory guidance questions. No significant correlations were found between gender or years of practice and knowledge scores. Respondents’ confidence in detecting caries was significantly associated with the knowledge score of the anticipatory guidance (P = .003). Fewer than half of the respondents considered prescribing sugar-free syrup (47.4%) and counselled patients regarding the use of mouthguards during sports for schoolchildren (39%). Conclusions The majority of paediatricians have adequate knowledge of the current anticipatory guidance of oral health issues, but they have insufficient knowledge of oral preventative measures and dental trauma. Adequate education and training in oral health are highly recommended.
Pediatricians' Knowledge of Children's Oral Health: A National Survey

A high percentage of dental caries (∼70%) was reported amongst 4- and 5-year-old Kuwaiti kindergarten children. Parents contact paediatricians several times during the child's early life. Paediatricians can play an important role in improving the oral health of their patients. The objective of the study is to evaluate the knowledge level and awareness of paediatricians and paediatric residents regarding children's oral health in Kuwait.

A national cross-sectional survey was distributed to paediatricians and paediatric residents practicing in Kuwait. Data concerning demographic variables, knowledge on dental caries preventive measures, current anticipatory guidance, and experience with dental problems and oral care were collected using online and paper-based surveys.

A total of 230 participants completed the survey, with a response rate of 50.1%. Most respondents (81%) had frequently noticed dental caries in children in their practice. Two-thirds of respondents felt confident in detecting dental caries. However, more than two-thirds were unfamiliar with preventive dental practices and the management of dental trauma. Only 16.5% of the respondents got a satisfactory knowledge score on the preventive measure questions, and nearly 51% had satisfactory knowledge on the recent anticipatory guidance questions. No significant correlations were found between gender or years of practice and knowledge scores. Respondents’ confidence in detecting caries was significantly associated with the knowledge score of the anticipatory guidance (P = .003). Fewer than half of the respondents considered prescribing sugar-free syrup (47.4%) and counselled patients regarding the use of mouthguards during sports for schoolchildren (39%).

The majority of paediatricians have adequate knowledge of the current anticipatory guidance of oral health issues, but they have insufficient knowledge of oral preventative measures and dental trauma. Adequate education and training in oral health are highly recommended.

Early childhood caries (ECC) is a major worldwide infectious oral health problem that affects preschool children. ECC occurs as a result of the interaction of many risk factors, such as pathogenic microorganisms, sugary diets, poor oral hygiene, low socioeconomic status, and irregular dental visits., Despite recommendations for young children to visit a dentist by 12 months of age, many parents often take their children to the dentist only when a dental problem becomes severe and causes pain or discomfort. The World Health Organization (WHO) reported that about 60% to 90% of preschool children are affected by ECC in most countries. The prevalence remains high in developing countries (up to 70%) and amongst children of low-income and minority status in developed countries. In Kuwait, the prevalence rates of ECC in 4- and 5-year-old children were 68% and 76%, respectively. This is similar to the prevalence reported in some Middle Eastern countries., Oral health has a significant impact on children's general health., ECC often results in pain and swelling that lead to problems in eating, speaking, and aesthetics. Moreover, the consequences of ECC have been associated with more emergency room visits, high treatment costs, loss of school days, compromised learning ability, and reduced oral health-related quality of life. Parents usually contact paediatricians several times during the child's early life. Paediatricians are often the primary care providers of young children when ECC may develop. Therefore, paediatricians can play a vital role in improving the oral health of their patients. They may provide preventive information, early caries risk assessment, early detection, and appropriate referrals that help in the child's growth and development. Unfortunately, paediatricians receive insufficient education on oral health during their medical training., Therefore, they should seek to know the updated knowledge and information related to oral health preventive measures. The increasing prevalence of preschool children's dental caries experience in Kuwait necessitates further attention to assess paediatricians’ overall knowledge, attitudes, and practices regarding children's oral health. Therefore, the current national study aimed to evaluate paediatricians’ and paediatric residents knowledge levels and practice regarding children's oral health in Kuwait.

This work was a national cross-sectional survey study that was conducted following the standard statements of the STROBE guidelines and was approved by the ethical committee of Kuwait University Health Sciences Centre and the Ministry of Health in Kuwait. The study population comprised paediatricians and paediatric residents who provide health care for children in Kuwait. They were identified using the membership databases of the Kuwait Medical Association (KMA) and the Kuwait Pediatric Association (KPA). To get a medical license and practice in Kuwait, one must be a member of KMA. There was a total of 532 registered members (residents, paediatricians) in the database. Based on the current data, the representative sample size was calculated using the CheckMarket survey tool. The minimum required number of respondents was predicted to be 224 to have a confidence level of 95% with an estimated 5% margin of error. To achieve an estimated 50% response rate, the minimum number to invite was 448. A structured questionnaire was adapted from previous surveys in the literature.21, 22, 23, 24, 25 Then, it was piloted with a group of 10 paediatric residents and 10 paediatricians who were not included in the study results. No further changes were made. All items in the questionnaire were assessed for content and face validity amongst the pilot group using a Likert scale. All participants found the questionnaire to be understandable and comprehensible. Brief information about children's dental caries experience in Kuwait and the study aims were provided on the cover page. The questionnaire included 5 sections. The first section obtained the sociodemographic characteristics of participants (eg, age, gender, years of practice, practice sector, place of specialty degree, number of children they treat per day, and oral health education during medical school/residency). The second section consisted of 6 questions (yes/no) related to the participant's knowledge of preventive measures for children's oral health. The third section contained 12 knowledge-based questions (yes/no) on current anticipatory guidance and assessment practices during the childcare visit. The third section contained 12 knowledge-based questions (yes/no) on current anticipatory guidance and assessment practices during the childcare visit, based on the the recommendations of the American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD). The fourth and fifth sections of the questionnaire addressed the participants’ experience with paediatric dental problems and aspects of continuing education, respectively. The questionnaire was not expected to take longer than 10 minutes to complete. Data were collected between January and March 2019. Recruitment was done by distributing the questionnaire in 2 different formats. First, the online surveys using Google Forms (https://www.google.com/forms) were sent to all registered KMA and KPA members’ email addresses and WhatsApp (https://www.whatsapp.com). Two follow-up reminders to complete the survey were sent 2 weeks apart. Then, the paper surveys were given to 314 registered attendees at the 4th International Pediatric Conference, which took place in Kuwait in 2019. The conference participants were asked not to complete the survey if they had already returned the online surveys. Participation was anonymous and voluntary. Only those who were willing to participate in the study and provided complete surveys were included. The knowledge level of participants on oral preventive measures and current anticipatory guidance and assessment practices was determined based on their total knowledge scores. The knowledge questions were scored as correct or incorrect according to the recommendations of the AAP and AAPD.,26, 27, 28, 29 A score of 1 was given for the correct answer and 0 for incorrect or unknown answers. A total knowledge score was calculated and then classified into tertiles: • Poor score: <50% of the correct answers • Fair score: 50%–75% of the correct answers • Satisfactory score: >75% of the correct answers Data were entered into an Excel spreadsheet and then analysed using Statistical Package for the Social Science version 20.0 software (SPSS Inc.). Descriptive statistics (frequency, percentage, mean) were determined. The chi-square test was used to determine the associations between the main outcome variable and other categorical variables. All P values <.05 were considered statistically significant.

Of the 532 registered members in the database, all were invited to take part in the online study survey; 41 were returned because of incorrect email addresses and phone numbers. Of the remaining 491 members with valid addresses, 13 reported that they had retired and 19 reported that they did not provide care for young children (surgical specialists or administrators). Therefore, from a pool of 459 eligible members, a total of 72 online surveys were completed. For the paper survey, out of 314 conference attendees, 31 reported their completion of the online survey. Of the 283 eligible attendees, 158 agreed to participate and completed the paper survey (response rate, 55.8%). Therefore, a total of 230 agreed and completed online and paper surveys for a response rate of 50.1%. Table 1 shows the sociodemographic characteristics of the study participants. The study sample included 194 paediatricians (84.3%) and 36 paediatric residents (15.7%). There were 127 female respondents (55.2%) and 103 male respondents (44.8%). More than a third of the respondents (37.8%) were aged 35 to 44 years, and only 12.2% were older than 55 years old. Almost one-third of the respondents (28.7%) had more than 20 years of practice, and 12.6% of the respondents had less than 5 years of practice. Two-thirds of respondents (62.2%) work in the public sector. About half of the respondents (47%) reported that they see 10 to 25 patients daily. The majority of respondents (64.3%) were board-certified. When asked about studying any dental health–related subjects during the medical school or residency programme, 66.5% and 72.2% of respondents denied this, respectively. The knowledge level of participants on the oral preventive measures was investigated and is described in Table 2. Most respondents were aware that baby bottle use is not the only cause of ECC (62.2%), and the recommended age for a child's first dental visit is 1 year (61.7%). Around half of the respondents knew that a 3-month-old child did not require fluoride supplementation (47%), that bacterial transmission can occur from mother to child (55.2%), that dental sealants are not often applied to primary teeth (50.9%), and that fluoridated toothpaste should be used in children younger than 3 years (47.9%). Only 16.5% of respondents (n = 38) correctly answered all 6 questions and were considered to have a satisfactory level of knowledge. More than half of the respondents (56.1%) had a fair level of knowledge, and a third of the respondents (27.4%) had a poor knowledge score (Figure 1). There were no significant associations found between the knowledge level on the preventive measures and the following variables: gender (χ2 (2) = 0.303; P = .859), years of practice (χ2 (2) = 10.5, P = .230), board certification (χ2 (2) = 0.728; P = .695), whether dental subjects were studied in medical school or residency (χ2 (2) = 3.814; P = .149), or number of patients seen per day (χ2 (4) = 6.88; P = .142). Regarding participants’ knowledge of the current anticipatory guidance and assessment practices (Table 3), the majority claimed that they inquired about infants’ bottle use at bedtime (79.6%) and children's oral habits (65.2%) and they examined children's teeth for dental caries (72.2%). Furthermore, they counselled on dental visits (67.4%), the importance of toothbrushing (73.9%), and children's sugar consumption (74.3%). Only half of the respondents considered prescribing sugar-free syrup (47.4%), and about 39% counselled on the use of mouthguards during sports for schoolchildren. In addition, when asked about their opinion on specific dental practices to be part of the routine well-child visit, most respondents (85%) agreed to assess the dental problems and counsel on their prevention (Table 3). Two-thirds (60.9%) acknowledged referring the child to a dentist at age 1. Additionally, half of them (54.8%) considered applying fluoride varnish in the office. Overall, 50% of participants had satisfactory knowledge levels of the current anticipatory guidance and assessment practices (shown in Figure 1).When investigating the association between the knowledge score and other variables, no significant associations were found with gender (χ2 (2) = 0.767, P = .681), years of practice (χ2 (2) = 8.7, P = .368), board certification (χ2 (2) = 1.127; P = .569), or exposure to dental subjects in school (χ2 (2) = 3.626; P = .163). However, participants who see a high number of patients daily had significantly greater knowledge of the current anticipatory guidance (χ2 (4) = 15.153; P = .004). The participants’ experiences with dental problems and dental care are presented in Table 4. Nearly 80% of the respondents had noticed ECC in young children on a monthly (43.5%) or a weekly basis (37.8%) in their practice. Moreover, half of the respondents frequently noticed dental caries in school-aged children (51.3%) on a weekly basis in their practice. Many respondents (63.5%) were confident in detecting dental caries. Of those, 70% had a satisfactory knowledge level of the current anticipatory guidance and assessment practices compared to the respondents who were not confident (30%, χ2 (2) =11.5, P = .003). In contrast, only 19.2% of confident practitioners had a satisfactory knowledge level of preventive measures. There was no significant effect of number of years of practice on confidence level (χ2 (4) = 5.1, P = .271). Many participants were unfamiliar with preventive dental practices such as fluoride varnish (68.7%) and dental sealants (73.9%) or with the management of dental trauma (74.8%). About third of respondents (30.9%) documented that they received information about oral health, the primary information source being the internet. (21.7%), followed by continuing education courses (12.2%) and books (11.3%). Few respondents got information from scientific journals (5.7%). The necessity of having a continuing education course regarding children's oral health has been strongly agreed upon by respondents (85.2%).

Many surveys have been conducted internationally to investigate the role of nondental practitioners in improving children's oral health outcomes. Even though the prevalence of dental caries in children is extremely high in Kuwait, no study has been previously conducted to explore such important role. Therefore, this is the first national survey to investigate paediatricians’ knowledge and awareness regarding children's oral health in Kuwait. Oral health education differed remarkably amongst several countries, and it was mainly delivered through continuing education and practical experience. The current study showed that most respondents did not receive oral health education in medical school (66.5%) or residency programmes (72.2%). A similar finding was reported (67%) in a recent European study, and an even higher percentage (90.4%) was documented in neighboring Saudi Arabia. Inadequate knowledge or training on oral health issues may be a barrier for paediatricians to effectively promote children's oral health. In the current survey, deficits of key knowledge related to dental caries preventive measures were spotted amongst half of the paediatricians. They were unaware of the transmission of cariogenic bacteria from mother to child and the international recommendations on specific interventions such as fluoride therapy and dental sealants. Other studies have documented similar findings in the knowledge of preventive measures,32, 33, 34, 35, 36 but a better knowledge of transmission was reported in US and European studies., Regarding the first dental visit, AAP and AAPD recommend that all children have their initial dental visit no later than their first birthday. Two-thirds of respondents in the current survey supported the dental referral of children by 1 year of age. They believed that it should be performed during the child's physical examination. This result was high compared to what was previously reported.,31, 32, 33, 34 According to other researchers, half of their responders recommended children's first dental visit be between the ages of 1 and 3.,,, Despite many paediatricians being aware of the recommended referral, Karasz et al found that few managed to complete the referral. Most paediatricians in the present study claimed that they assess children's teeth and include anticipatory guidance on oral health issues in their well-child visits. Variable rates were previously reported for the examination of children's teeth. Rates ranged from 90% in the US and Canadian studies, to 60% in the Saudi and Emirati studies, and lower rates in some Indian studies., Most paediatricians in the present survey (85%) believed that assessing dental problems and counselling on their prevention should be part of routine childcare visits. Two-thirds (64%) of our respondents felt confident enough to detect dental caries. Studies conducted in the US, Europe, and India found similar results.,,, Of note, in the present study, no significant effect of years of practice was shown in the paediatricians’ confidence in detecting caries. However, Hadjipanayis et al found that experienced paediatricians (>10 years in practice) felt confident about identifying dental caries. Around half of the surveyed paediatricians agreed that they should apply fluoride varnish during the routine childcare visit. Lewis et al found that although 21% of paediatricians agreed that the application of fluoride varnish should be a part of well-child care, only 4% of them provided that. Paediatricians can play a vital role in preventing dental caries by offering the application of fluoride varnish in their practice. It is an effortless procedure and does not require special training or operatory. About half of the paediatricians in the present study were likely to consider sugar-free syrup prescriptions. This result was inconsistent with a study by Babu et al. The finding was not investigated in previous similar studies.,,30, 31, 32, 33, 34, 35, 36 In general, many paediatricians believe that sugar-free medications are not as sweet as sugar-containing medications and are more expensive., With increased participation by children in different sports, the risk of orofacial injuries is rising. About 30% of oral injuries in children have been reported to occur during sports activities. AAPD and the Academy for Sports Dentistry recommend using mouthguards for all children engaged in contact sports. In the current study, more than two-thirds were not aware of the management of dental trauma. Also, few respondents (38%) counselled using sports mouthguards for schoolchildren. Educating paediatricians on the need for and use of mouthguards for children who engage in contact sports is essential. Overall, half of the respondents in the current study demonstrated fair knowledge of preventive measures and satisfactory knowledge of anticipatory guidance and assessment practices. This might be explained by the fact that many respondents were board-certified and followed AAP guidelines. However, the findings still imply significant gaps in preventive oral health and dental trauma topics. In our study, years of practice have not shown significant associations with investigated knowledge levels. Most of our respondents had 11 or more years of experience. Interestingly, Oge et al found that total number of years’ experience was linked to a major decline in oral health knowledge. Nevertheless, in our study, paediatricians who see more patients daily in their practice have a better knowledge level of the current anticipatory guidance. In the present study, both paper-based surveys and online surveys were used. The online surveys produced lower response rates compared to the paper-based surveys. The mixed-mode survey administration has been found to produce the highest response rate, but at a considerably greater cost. The respondents in the current study appeared to have a particular interest in the survey results and might have felt a professional obligation to complete the survey. The majority showed their need for further continuing education courses on the child's oral health. There are some limitations in the current study. As with any survey, there is the potential for response bias. Although the response rate of 50.1% is consistent with previous surveys,, the nonrespondents possibly had other experiences and opinions regarding oral health in paediatric practice. Also, this study did not include family physicians since most of them work in polyclinics and often refer children's cases to paediatricians to evaluate; the rest work in administrative jobs. Even though the current survey research has validity problems whereby the provided answers may not reflect the participants’ true knowledge and practice, the findings of this survey would establish baseline data about paediatricians’ oral health knowledge in Kuwait. Also, planning educational courses based on actual paediatricians’ needs is fundamental to providing effective ones. In addition, the current data generated from Kuwait and data from neighbouring countries, would give a clearer picture to the Gulf Cooperation Council authorities in health care. The collaboration between both medical and dental sectors is necessary to promote children's oral health in the region. Further research can be conducted after implementing the educational courses to explore the change in paediatricians’ attitudes and practice on oral health.

Insufficient knowledge levels on the preventative measures of dental caries and dental trauma have been documented amongst paediatricians in Kuwait. However, they had adequate knowledge levels on the current anticipatory guidance of children's oral health. Many paediatricians were willing to perform appropriate oral assessments, make dental referrals, and apply fluoride varnish. Continuing oral health education courses are required to ensure high-quality care for children locally and internationally.

None disclosed.