Knowledge, Attitudes, and Practices of

Pediatric Dentists Regarding Speech

Evaluation of Patients: Implications for
Dental Education
Lisa Van Eyndhoven, DDS, MS; Steven Chussid, DDS; Richard K. Yoon, DDS
Abstract: The aim of this cross-sectional study was to determine pediatric dentists’ attitudes about speech evaluation in the dental
setting and assess their knowledge of speech development and pathology. In October 2013, members of the American Academy
of Pediatric Dentistry were invited to participate in an electronic questionnaire. Categories of questions were demographics, atti-
tudes and conidence in speech pathology, and theoretical and practical knowledge of speech development and speech pathology.
Theoretical knowledge was assessed using questions about phonetics and speech milestones. Practical knowledge was determined
with three 30-second interview-style video clips. A total of 539 responses were received for a response rate of 10.4%. The major-
ity of respondents reported feeling that speech evaluation should be part of the pediatric dental visit (72.8%) and felt conident in
their ability to detect speech issues (73.2%). However, they did poorly on the theoretical knowledge questions (41.9%) as well
as the practical knowledge questions (8.5%). There was a statistically signiicant difference in theoretical score between gender
and type of occupation (p<0.05). This difference was not observed when examining practical knowledge. This study suggests that
although pediatric dentists are in an ideal position to aid in the detection of speech issues, they currently have insuficient training
and knowledge to do so.
Dr. Van Eyndhoven is an associate pediatric dentist in private practice, New York, NY, and former postdoctoral resident fellow,
Columbia University Medical Center; Dr. Chussid is Associate Professor of Dental Medicine and Chair, Section of Growth and
Development, Columbia University Medical Center; and Dr. Yoon is Associate Professor of Dental Medicine and Program Direc-
tor, Advanced Specialty Education in Pediatric Dentistry, Columbia University Medical Center. Direct correspondence to Dr.
Richard K. Yoon, Columbia University College of Dental Medicine, 630 W. 168th Street, New York, NY 10032; 212-305-1043;
rky1@cumc.columbia.edu.
Keywords: advanced dental education, graduate dental education, pediatric dentistry, speech, pathology, oral examination,
continuing education
Submitted for publication 1/23/15; accepted 5/12/15

A
ccording to the American Speech-Language-
Hearing Association (ASHA), approxi-
mately 17% of Americans suffer from a com-
munication disorder, and about 7% of children have
speciic language impairment.1 Early identiication of
speech disorders is important because they may prog-
ress to lifelong communicative impairments if left
untreated. Often a precursor for learning disabilities,
there is a concurrence between speech disorder and
autism, behavior disorders, and neurologic impair-
ments.2 Language issues can also lead to problems
with self-esteem and “maladaption of emotional and
social reactions.”3
According to ASHA, early speech and lan-
guage intervention with expressive language and
vocabulary issues has a positive effect.1 Although
this connection suggests that early diagnosis is ben-
eicial to the child, most speech pathology is in fact
not recognized until school age. To aid in the early
identiication of children with speech issues, speech
language pathologists (SLPs) work with physicians,
occupational therapists, and early childhood educa-
tors.4 However, there is currently little interaction
between SLPs and pediatric dentists.
Basic speech and language milestones are
available in the Handbook of Pediatric Dentistry
published by the American Academy of Pediatric
Dentistry (AAPD) although it is unclear how much
knowledge pediatric dentists have in this ield or have
received during their clinical training.5 Furthermore,
it is unclear how much speech and language training
pediatric dentists receive in their specialty through
continuing education. Awareness of speech delay
and speech pathology can aid pediatric dentists in
determining the best way to treat a child, not only
in treatment planning but also in behavior manage-
ment.6 A irm understanding of the linguistic matu-
rity of the child helps pediatric dentists adjust their
techniques to reduce miscommunication, which has
been linked to misbehavior.7

November 2015 ■ Journal of Dental Education 1279

 While pediatric dentists play a critical role in
evaluation of the developing oral structures and the
diagnosis of oral pathology in the young child and
also rely heavily on communication to perform ade-
quate treatment, it is unclear what their role should be
in the diagnosis, referral, and treatment of speech pa-
thology. The aims of this cross-sectional study were
therefore to 1) determine pediatric dentists’ attitudes
about training in speech and language pathology; 2)
determine their attitudes regarding incorporation of
speech evaluation in the routine dental examination;
and 3) evaluate their knowledge of normal speech
development and speech pathology.
Methods
All study procedures and waiver of consents
were approved by The Research Compliance and
Administration System at Columbia University
Medical Center, protocol number AAAL4850. The
research team developed and beta tested a survey
instrument. Survey testing was accomplished with 12
pediatric dentists (eight in clinical practice and four
in academe) with various years of clinical experience.
The beta test was used to clarify and reine survey
questions and eliminate unclear items.
In October 2013, 5,200 active non-retired
members of the AAPD who had graduated from a
postdoctoral program in the U.S. or abroad were in-
vited via email to participate in a 33-item electronic
questionnaire hosted and administered by Qualtrics
Survey Software and Research Suite (Qualtrics,
Provo, UT, USA). Questionnaire items contained
questions regarding demographics, attitudes and
confidence in speech pathology, and theoretical
knowledge and practical knowledge of speech de-
velopment and speech pathology.
Demographic questions asked about respon-
dents’ gender, birth year, race/ethnicity, type of
postdoctoral program attended, year of graduation
from program, diploma obtained, occupation, and
training in speech pathology including participa-
tion in a craniofacial team. Survey recipients were
asked how conident they felt in their training in
speech pathology and whether they felt conident
in their ability to identify speech issues. Attitudes
were determined by inquiring about the respondents’
interest in attending continuing education courses in
speech pathology, how strongly they agreed with the
incorporation of speech pathology in dental training
(predoctoral and postdoctoral), and how they felt
1280
about the incorporation of speech evaluation in the
dental recall examination.
Theoretical knowledge was assessed with ques-
tions about phonetics, speech and oral milestones
(e.g., drooling and swallowing), and speech therapy.
These questions were derived from the AAPD hand-
book and the American Academy of Pediatrics (AAP)
Bright Futures guidelines.5,8
Practical knowledge was assessed with three
30-second interview-style video clips obtained from
a video-sharing web-based server. The irst video
featured a three-year-old girl with apraxia (a speech
production disorder), the second a normally devel-
oping four-year-old girl, and the third a ten-year-old
boy with autism and social language impairment.
Participants were asked whether the child would
beneit from a referral to an SLP and to identify any
speech issues if any. All videos and questions were
reviewed and veriied by a registered SLP on the
craniofacial team.
The respondents remained anonymous, and no
identifying information was obtained. Descriptive
statistical analysis was conducted using the Qualtrics
web-based survey and SPSS Statistics for Windows,
Version 22.0 (IBM Corp., Armonk, NY, USA) to gen-
erate percentages, t-tests, ANOVA, and linear regres-
sion analysis. Statistical signiicance was set at 0.05.
Results
A total of 539 responses were received for a
response rate of 10.4%. Approximately 50% of the
respondents identiied themselves as female (N=278),
and the majority (75.7%, N=408) identiied as being
white/Caucasian with the second most predominant
ethnic group being Asian (10.2%, N=55). Ages varied
from <30 years (5%), 30-40 years (38%), to 40-50
years (22%); the remaining respondents were above
the age of 50. Approximately 40% had graduated
from their postdoctoral program after 2005, and 53%
graduated from a hospital-based program afiliated
with a dental school. During their postdoctoral pro-
gram, 70% had participated in a craniofacial team.
The majority of the respondents (87.6%, N=472)
reported their primary occupation as clinical practice,
with the majority in practice in a private dental ofice
(81.0%, N=437). Of the remaining respondents, 51%
identiied themselves as dental educators (N=51);
only one reported being a dental researcher.
Approximately 73% of the responding pedi-
atric dentists agreed that speech evaluation should
Journal of Dental Education ■ Volume 79, Number 11
be part of the routine pediatric dental examination,
and 73.2% said they felt conident in their ability to
identify speech delays in the clinical pediatric dental
setting. While 95.4% reported feeling that training
in speech and language development was important
during their postdoctoral program, only 41.2% felt
their training suficiently prepared them to identify
common speech pathologies. In addition, 45.1% said
they were likely to attend a continuing education
course in speech pathology (Table 1).
The average score of correctly answered theo-
retical questions was 41.9%, and less than 1% of the
respondents correctly identiied all speech and oral
milestones. Only 8.5% provided correct referrals to
an SLP to all three children in the videos, while only
2.8% correctly identiied speech issues (if any) in the
three children (Table 1).
There was a statistically signiicant difference
in theoretical score between type of occupation and
gender. The average theoretical score for clinical pe-
diatric dentists was 4.08 (out of a possible 12), and the
average theoretical score for pediatric dentists who
identiied themselves as dental educators/dental re-
searchers/other was 5.27 with a mean score difference
of 1.19 (p<0.05). This difference was not observed
when comparing practical knowledge scores (Figure
1). The average theoretical score for female pediatric
dentists was 4.57 (out of a possible 12), and the aver-
age theoretical score for male pediatric dentists was
3.95 with a mean score difference of 0.62 (p<0.05).
This difference was not observed when comparing
practical knowledge scores (Figure 2).
There was no statistically signiicant correla-
tion between theoretical or practical score with regard
to race or ethnicity, type of postdoctoral program, or
graduation year. Exposure to speech pathology train-
ing in either postdoctoral training or via a continuing
education course led to an increase in theoretical and
practical knowledge, but this increase was not statisti-
cally signiicant (Figure 3). There was also no sta-
tistically signiicant difference in one-way ANOVA
analysis of the effect of quantity of training in speech
pathology on theoretical and practical knowledge.
Discussion
Speech is produced when sounds are formed
by the vocal chords and are altered by the movement
of the lips, tongue, and teeth. Speech therapists iden-
tify problems with this process and diagnose delays
and pathologies such as apraxia, dysarthria, and
articulation disorders. They use various techniques
to overcome these issues and also collaborate with
other health care professionals such as pediatricians
and physicians who specialize in ear, nose, and throat
as well as occupational therapists and early childhood
educators.
Predy and Meintzer reviewed the role of speech
evaluation in the well-child visit with the pediatri-
cian/family physician in 1982.3 They described how
speech and language development is often a precursor
for learning disabilities and that most speech pathol-
ogy is not recognized until school age. Since such
issues can lead to problems with self-esteem and
“maladaption of emotional and social reactions” and
since the family physician is often the irst person
consulted about speech issues, they argued that there
should be greater awareness of speech evaluation on
the part of the family physician.
The meta-analysis done by Law et al. con-
cluded that there was a positive effect of speech and
language therapy interventions for children with ex-
pressive phonological and vocabulary issues.2 They

Table 1. Descriptive data for attitudes and knowledge of participating pediatric dentists
Number (Total Respondents) Percentage

Attitudes
Likely to attend a continuing education course in speech pathology 243 (539) 45.1%
Agreed that training in speech pathology should be part of postdoctoral training 501 (525) 95.4%
Theoretical knowledge
Average of correctly answered theoretical questions 226 (539) 41.9%
Participants who correctly identified all speech and oral milestones 3 (539) 0.6%
Practical knowledge
Participants who provided correct referrals to children from the videos 46 (539) 8.5%
Participants who correctly identified any speech issues in children from the videos 15 (539) 2.8%

November 2015 ■ Journal of Dental Education 1281

 Figure 1. Mean theoretical and practical scores of participating clinical pediatric dentists in comparison with dental
educators/researchers/other

Note: Scores on both theoretical and practical questions are out of a possible 12.
*Mean score difference=-1.19 (p<0.05)

Figure 2. Mean theoretical and practical scores of participating female pediatric dentists in comparison with male
pediatric dentists

Note: Scores on both theoretical and practical questions are out of a possible 12.
*Mean score difference=-0.62 (p<0.05)

1282 Journal of Dental Education ■ Volume 79, Number 11

Figure 3. Mean theoretical and practical scores of participants with and without formal training in postdoctoral
program or continuing education courses
Note: Scores on both theoretical and practical questions are out of a possible 12. No statistically significant difference was found.
also described a concurrence between speech disor-
der and autism, behavior disorder, and neurologic
impairment. This relationship suggests that early
diagnosis and treatment in certain circumstances
would beneit the child. Lawrence and Bateman in
their literature review described a 12-minute method
that would aid in early diagnosis and can be incor-
porated into any pediatric practice.4
Dentists learn how the proper alignment of
teeth helps with the phonation. Disciplines such as
prosthodontics and orthodontics address these struc-
tural issues to help aid functional ones. Both Fawcus
and Hopkin described the effect of malocclusions
and skeletal disharmony on speech development.9,10
Those studies promoted the role of the orthodontist
through the use of interceptive and traditional ortho-
dontics in combination with speech therapy to guide
the speech development of the child.
Pediatric dentists are trained in how the oral
structures of a child develop. They are aware in how
they can affect these structures. For instance, the early
extraction of primary incisors can affect speech pro-
November 2015 ■ Journal of Dental Education
duction.11,12 This connection suggests a larger role for
the pediatric dentist in the detection of early speech
pathology. Since pediatric dentists are involved in
treating young children and since communication is
essential for cooperation and effective treatment, they
are in a good position to help identify any delays.6
Awareness of speech delay and speech pathol-
ogy can aid pediatric dentists in determining the best
way to treat a child. For instance, Pinkham describes
how misbehavior is often linked to miscommu-
nication.7 A better understanding of the linguistic
maturity of their patients will help pediatric dentists
determine the child’s behavior in a treatment setting,
allowing them to adjust their behavior management
techniques. Since pediatric dentists have such a direct
impact on the developing dentition and also play such
a pivotal role in the overall development of the child,
they should be more aware of language milestones
and language disorders.
Though most pediatric dentists (73.2%) in our
study said they were conident in their ability to diag-
nose speech issues, on average they did not perform
1283
 well on either the theoretical or the practical speech
pathology questions. Pediatric dentists performed the
best on the section analyzing knowledge of speech
therapy and oral milestones (such as drooling and
swallowing) with an average score of 48.9%, while
they performed the worst on the section evaluating
knowledge of phonemes and phonetics (22.6%). It
was expected that they would perform well on the
section of speech and language milestones since
those are listed in the AAPD handbook; however,
the average score was a 30.2% with only 13.1% of
the sample scoring higher than 50%.
There was no statistically significant cor-
relation between theoretical or practical score and
ethnicity, type of postdoctoral program, graduation
year, or exposure to speech pathology in continuing
education, postdoctoral, or predoctoral courses. It
appears that the pediatric dentists were unilaterally
unprepared to detect speech issues, and their race/
ethnicity, type of training they received, or amount
of clinical experience seemed to have no impact on
their ability to do so.
There was a statistically signiicant difference
in theoretical score between gender and type of oc-
cupation. The average theoretical score for clinical
pediatric dentists was 4.08 (out of a possible 12),
and the average theoretical score for pediatric den-
tists who identiied themselves as dental educators/
dental researchers/other was 5.27, for a mean score
difference of 1.19 (p<0.05). This difference was
not observed when comparing practical knowledge
scores (Figure 1). The average theoretical score for
female pediatric dentists was 4.57 (out of a possible
12), and the average theoretical score for male pedi-
atric dentists was 3.95, for a mean score difference
of 0.62 (p<0.05). This difference was not observed
when comparing practical knowledge scores (Figure
2). In general, participants with training in speech
pathology either in postdoctoral education or continu-
ing education courses did better on both theoretical
and practical portions although the difference was
not statistically signiicant (Figure 3).
The limitations to this study were primarily the
small number of participants. With a 10.4% response
rate, this study represents only a small proportion of
pediatric dentists in the United States. In addition,
technical dificulties further limited the usable sample
size. The electronic questionnaire had both embed-
ded video-sharing web-based clips and links to the
videos and due to limitations of various software
programs, a large number of respondents were unable
1284
to view the videos and therefore unable to answer the
questions pertaining to them. Though this problem
further reduced the amount of usable data, the use of
embedded electronic media has the ability to enhance
both education and evaluation.
Conclusion
Because pediatric dentists are in a good posi-
tion to detect early speech pathology, the aim of this
study was to determine their attitudes about speech
evaluation in the dental setting and assess their
knowledge of speech development and pathology.
Although only 10.4% of the total sample (members
of the American Academy of Pediatric Dentistry)
participated in the survey, the results suggest that
pediatric dentists have insuficient knowledge and
training to evaluate their patients’ speech develop-
ment and pathology. However, while the participants’
performance on both the theoretical and practical
evaluations was poor, the majority agreed that train-
ing in speech pathology is an important component
of the education of the pediatric dentist. They also
agreed that speech evaluation should be in the diag-
nostic scope of the pediatric dentist and should be a
part of the dental examination.
Disclosure
The authors reported no conlicts of interest.
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