Covering letter

To,

The Editor in Chief

Journal of Indian Society of Pedodontics and Preventive Dentistry

Sub: Submission of Manuscript for publication

Respected sir,

The study in the submitted manuscript titled ‘Awareness of among pediatricians regarding

oral health care in children including those with special health care needs: A cross-

sectional survey’ has assessesd the knowledge, attitude, and practices among pediatricians

regarding oral health in children including those with special health healthcare needs (CSHCN).

The study has evaluated the knowledge of pediatricians related to i) etiology and pathogenesis of

dental caries ii) oral hygiene measures for prevention of dental and gingival diseases iii) use of

fluoride and its role in caries prevention and iv) attitude and practices towards the oral health of

children with special health care needs (CSHCN).

The authors declares no conflict of interest. Research is independent and not funded by any

agency. We hereby transfer, assign, or otherwise convey all copyright ownership, including any

and all rights incidental there to, exclusively to the journal, in the event that such work is

published by the journal.

Thank you

DR RAHUL MORANKAR

Senior Resident. Unit of Pediatric Dentistry, Oral Health Sciences Center,

Post Graduate Institute of Medical Education and Research,Chandigarh

Email: captainrahul88@gmail.com Phone: 9855501651

Original article

Awareness of among pediatricians regarding oral health care in children including those

with special health care needs: A cross- sectional survey

Goyal Ashima, Morankar Rahul, Mehta Nishant, Gauba Krishan

Short title- Pediatricians awareness on oral health

1. Author: Dr Ashima Goyal (Goyal A)

MDS, Professor,

Unit of pedodontics and preventive dentistry

Oral Health Sciences Centre

PGIMER, Chandigarh.

ashimapgi@yahoo.in

2. Co-author: Dr Rahul Morankar (Morankar R )

MDS, Senior Resident

Unit of pedodontics and preventive dentistry

Oral Health Sciences Centre

PGIMER, Chandigarh.

captainrahul88@gmail.com

3. Co-author: Dr Nishant Mehta (Mehta N )

MDS, Senior Resident

Preventive and community dentistry

Oral Health Sciences Centre

PGIMER, Chandigarh.

captainrahul88@gmail.com

4. Co-author :Dr Krishan Gauba (Gauba K)

 MDS, Prof & Head

Oral Health Sciences Centre

PGIMER, Chandigarh.

gaubakrishan@gmail.com

Corresponding author address:

Dr Rahul Morankar

Room.no 202, Senior Resident

Unit of pedodontics and preventive dentistry

Oral Health Sciences Centre, PGIMER, Chandigarh -160012

Phone no. 9855501651

Email address: captainrahul88@gmail.com

Total number of pages- 12

Total number of Figures- 01

Total number of Tables- 03

Abstract words- 217

Text words- 1829

Awareness of pediatricians regarding oral health care in children including those with

special health care needs: A cross- sectional survey

Goyal Ashima, Morankar Rahul, Mehta Nishant, Gauba Krishan

ABSTRACT

Introduction- Pediatricians are the custodians of the overall health of children and are the ideal

healthcare personnel to impart information and instruction about oral health care. Aim- To

evaluate awareness of pediatricians regarding oral health care and prevention of oral diseases in

children including those with special health care needs (CSHCN). Design- A questionnaire based

cross sectional survey. Materials and methods- The study participants consists of 102 young

pediatricians working as a Junior and Senior residents. A questionnaire was formulated to

evaluate their knowledge about oral diseases and their prevention. The questionnaire also tested

the attitude and practices of pediatricians towards oral health of CSHCN. Results- The results

revealed majority of the pediatricians had correct knowledge about dental caries (60%), bottle

feeding (88.2%), tongue cleaning (83.3%) and medication causing gum enlargement (92.2%).

Few had correct knowledge about recommended age to start tooth brushing (35.3%) and

maximum recommended sugar exposures per day (35.3%). Although, majority (62.7%) had

correct knowledge about fluoride and its role caries prevention, however, very few (2.9%) knows

about recommended fluoride concentration in toothpaste for children The results also revealed

lack of awareness among pediatricians regarding oral health of CSHCN and their referral to a

dentist.Conclusion-The result of present study revealed lack of knowledge amongst pediatrician

about oral health care, prevention, and appropriate referral.

KEY WORDS : Pediatrician, Oral health care, Prevention, Special children

Introduction

Pediatricians as health care professionals supervise the process of growth and development from

birth onwards and provide guidance to the parents regarding feeding, maturation, immunization

and diseases.[1] Pediatricians are the custodians of overall health of children and are the ideal

healthcare personnel to impart information and instruction about health care including oral health

to the parents and caregivers. Oral health is an important component of general health and it is

often neglected, as most of the pediatricians are not trained to assess it and have an opinion that

it does not fall within their domain. [2]

The pediatricians are required to educate parents about basic preventive dental care, early

diagnosis of pathological changes in the oral cavity and appropriate referrals. [3] The pediatrician's

role in oral health care was formalized by the American Academy of Pediatrics (AAP) policy

statement in the year 2003, Oral Health Risk Assessment Timing and Establishment of the

Dental Home which recommends that pediatricians and other pediatric primary care providers

must incorporate preventive oral health education into their practices and children must undergo

an oral health risk assessment by a pediatrician or pediatric primary care provider by 6 months of

age. [4]

The yYoung pediatric patients visits a pediatrician very often. Studies have revealed that the

number of children (below one year) seen by a pediatrician are significantly higher compared to

a dentist.[5] Thus, pediatricians are considered to play a pivotal role in providing preventive oral

health care information and to diagnose oral diseases in children at an early age. The oral health

awareness among pediatrician and implementation of their oral health-related knowledge in their

practice can have a significant impact on prevention of oral disease in children. [6] Thus, the
present cross-sectional study was undertaken to assess the knowledge, attitude, and practices

among pediatricians regarding oral health in children including those with special health

healthcare needs (CSHCN).

Materials and methods

This wasis an institution based cross-sectional study carried out at Advance Pediatric Centre,

Post Graduate Institute of Medical Education and Research, Chandigarh. The study population

included 102 young pediatricians pursuing their residency program at the center working as

either junior orand senior residents. Junior resident were those having less than three years of

experience as pediatrician whereas senior residents had more than three years of experience.

Ethical clearance and informed consent

The study protocol was reviewed and approved by the institutional ethical and review committee

PGIMER, Chandigarh [Ethical clearance no. INT/ IEC/2015/695]. The questionnaires were

administered to the all the pediatricians who gave written informed consent and volunteered to

participate in the study. Before administering the questionnaire, the pediatricians were briefed

about the objectives of the study. The surveys reports were kept anonymous.

Pre-testing of the proforma

A self structured questionnaire was used to
collect data related to the knowledge among pediatricians about dental hard & soft tissue diseases
and measures to prevent them. The questionnaire was reviewed by experts (who were
active in the field of pediatric oral health) and content validity was ensured. A pilot study was conducted
to determine the test–retest reliability of the survey questions in the present scenario; 15 pediatricians who
completed the survey during the initial administration completed the survey 2 weeks later. The
respondents were also asked for feedback on clarity of the questions and whether there
was difficulty in answering the question or ambiguity as to what sort of answer was required. The
subjects
who participated in the pilot study were not included in the final sample.

Proforma details
A questionnaire was formulated which included questions related to the knowledge about dental

and gingival diseases and oral hygiene measures to prevent them. The questionnaire comprised

of both open and close ended questions to assess the depth of oral health care related knowledge

among these young pediatricians at the beginning of their career. The questionnaire formulated

evaluated the knowledge of i) etiology and pathogenesis of dental caries ii) oral hygiene

measures for prevention of dental and gingival diseases iii) use of fluoride and its role in caries

prevention and iv) attitude and practices towards the oral health of children with special health

care needs. The questionnaire was filled by all the participants in the presence of investigators

and no discussions were allowed. An ethical clearance was obtained from the Institute Ethical

Committee before commencement of the study [Ethical clearance no. INT/ IEC/2015/695]. After

collection of questionnaire principal investigator delivered a lecture to all the participating

pediatricians to improve their knowledge and awareness about oral health and explained them

about their role in prevention and control of oral diseases.

Results

The 102 study participants were comprised of 28 senior resident and 74 junior resident among

which 48 were males and 54 were females [Figure1]. The majority of pediatricians had correct

knowledge about dental caries (60%), bottle feeding (88.2%), tongue cleaning (83.3%) and

medication causing gum enlargement (92.2%). Few had correct knowledge about recommended

age to start tooth brushing (35.3%), critical salivary PH for tooth demineralization (32.4%) and

maximum recommended sugar exposures per day (35.3%) [Table 1]. Very few participating

pediatricians had correct knowledge about amount of fluoride in toothpaste recommended for
children (2.9%) and fluoride varnish (14.7%) [Table 2]. The evaluation of attitude and practices

of participating pediatricians towards the oral health of children with special health care needs

(CSHCN) revealed that very few (21.6%) always examine the oral health of CSHCN during their

general/physical examination and only 17.6% participating pediatricians give the advice

regarding tooth and tongue cleaning after consumption of sugar containing medications. Also,

there was a lack of appropriate referral among pediatricians as only 24.5% participating

pediatricians refer the CSHCN to the dentist for treatment [Table3].

Statistical analysis
Completed questionnaires were entered in a database using MS Excel (Microsoft Corporation, Redmond,
WA, USA). To test the reliability of the survey items, Cronbach’s alpha coefficient was used. Frequency
distributions and percentages were examined for each answer using SPSS version 21.0. Armonk, NY: IBM
Corp

Discussion

The present study was conducted with an objective to assess the knowledge, attitude, and

practices among the young pediatricians undergoing their residency program about etiology and

prevention of dental diseases. The results of the present study revealed that only 62.7% and

43.1% participating pediatrician had correct knowledge about dental caries and dental plaque

respectively. Dental caries is a most common oral disease and dental plaque is a principal

causative factor responsible for its occurrence. The young pediatric population visits a

pediatrician more often than a dentist. The knowledge about etiopathogenesis of oral diseases

plays a crucial role in disease prevention and its management. Pediatricians are considered to be

in a unique position to provide preventive oral information and to diagnose oral disease early at

its onset. [3]

64.7% pediatricians participated in the present study did not have correct knowledge about

recommended age to start tooth brushing in children. According to American academy of

pediatric dentistry (AAPD) as soon as the first tooth erupts into oral cavity brushing should be

started.[4,7] Sharma et al. reported that the importance of initiating oral hygiene practices before

and during tooth eruption of the first tooth was not seen to be prevalent among all pediatricians.
[8]
Majority of the pediatrician participated in the study (88.2%) had correct knowledge about

bottle feeding practices and its detrimental effects of on dentition. Shetty and Dixit in their study

reported that 98% of the pediatricians were aware that bottle feeding at night may cause dental

caries.[9] Bottle feeding at night has been found to be associated with increased caries burden in

children.[10]

54.9% participating pediatricians had correct knowledge about the importance of dental

treatment in primary teeth. In general, it is believed that primary teeth are get exfoliated on their

own and replaced by permanent teeth. Pediatricians are the ones who came across most

frequently with children compared to a dentist and therefore their knowledge about the

importance of dental treatment in primary teeth can have a significant impact on pediatric oral

health care. Indira at al. in their survey amongst pediatricians of Mysore, India found that about

93.8% of pediatricians were aware of pediatric dentistry as specialty and importance of dental

treatment in primary teeth. [11]

The questions related to etiopathogenesis of dental diseases revealed that 32.4% and 35.3%

pediatricians knew correctly about critical PH of saliva causing tooth demineralization and

maximum recommended sugar exposures per day respectively. Studies had proven a positive

association between sugar and dental caries.[12,13,14] AAPD encourages pediatric dentist and other
oral health care providers to eduacate the public about an association between frequent

consumption of carbohydrates and dental caries.[15]

The study results also revealed that 92.2% pediatrician were aware of drugs causing gum

enlargement. This is important as antiepileptics are one of the common group of drugs prescribed

by pediatricians for management of seizures. Antiepileptic medications like phenytoin,

phenobarbitone and to some extent carbamazepine have potential to cause gum enlargement, [16]

therefore, correct knowledge in this regard is essential as drug therapy can be monitored for its

effect on gums so that drug dose can be reduced or an alternative drug can be prescribed in a

situation where gingival enlargement occur.

Considering the role of fluoride in dental caries prevention, the study comprised of questions

related to pediatricians' knowledge regarding its use and role in caries protection. Although, the

majority of the pediatricians (62.7%) were aware of caries protective role of fluoride only few

i.e. 23%, 2.9% and 14.7% were having correct knowledge regarding use fluoridated toothpaste in

children, amount of fluoride recommended for children and application of fluoride varnish for

caries prevention respectively.The knowledge about use of fluoride in children is important as it

helps in prevention of dental caries, however this also protect the child from overexposure to

fluoride leading to dental fluorosis. [17]

Children with special healthcare needs (CSHCN) are the ones in which preventive oral health

care services have utmost importance because of difficulty in performing routine oral hygiene

practices compared to their normal counterparts. Dental treatment in these children is very

difficult to perform and many of them require general anesthesia/sedation for treatment. [18] In the

present study, about 16.7 % participating pediatricians admitted that they always came across
CSHCN during their routine practice while those came across often and sometimes were 31.4%

and 50% respectively emphasizing the need for their increased awareness about oral health in

CSHCN.The study also revealed that only 21.6% of pediatricians always performs the oral health

examination of CSHCN during their general examination. The possible rationale either could be

the lack of substantial knowledge about oral health or time constraint. This is significant

considering the role of the pediatrician in the prevention of oral diseases and increased risk oral

diseases among CSHCN. These children usually consume one or more medication. These

medicaments are sweetened to improve their acceptance by children.[19] These sugary

medicaments lead to an increase in a number of sugar exposures per day which is associated with

increased risk of developing dental caries.[20] 71.6% of pediatricians in the present study advice

the CSHCN about the cleaning of teeth and tongue after consumption of sugar containing

medications. A survey conducted in Rio De Janeiro, Brazil stated that 80.8% pediatricians were

aware of the fact that sugar-containing medicines are detrimental to dental health. However, only

50.8% recommended oral hygiene after its consumption. [21] Similarly, this study also revealed

lack of awareness among pediatricians regarding referral to a dentist as only 24.5% always refer

CSHCN with oral diseases to a dentist for their treatment needs. Similar findings were found in a

survey conducted amongst pediatricians in North Karnataka as only 57% of the pediatricians

referred to a dentist as soon as caries was noticed in children and 62% of the pediatricians

referred only when pain and swelling were developed.[10]

Conclusion- The results of the present study revealed that although the pediatricians are aware

of many aspects of oral health,however,overall there is a lack of knowledge amongst pediatrician

about oral diseases and their causative factors, oral hygiene practices and use of fluoride and its
role in caries prevention. The results also emphasizes the need for timely referral of children with

unmet dental needs to a dentist by pediatricians.

Recommendation- The study revealed the necessity to educate the pediatricians about

etiopathogenesis of oral diseases and possible measures to prevent them. Oral health care

knowledge should be an integral part of pediatricians training to increase their knowledge about

oral diseases so that oral diseases can be timely diagnosed and promptly treated to reduce unmet

dental needs to as minimum as possible.

Acknowledgement: None.

Conflicts of interest: Authors declares no conflict of interest. Research is independent and not

funded by any agency.

References:

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of pediatricians regarding the prevention of oral diseases in Italy. BMC Public Health

2006; 6(176): 1-8.

2. Krol DM. Children’s oral health and the role of the pediatrician. Curr Opin Pediatr

2010;22:804-808.

3. Ripa LW. The role of the pediatrician in dental caries detection and prevention. Pediatrics

1974;54:176-182.

4. Berkowitz SF. American Academy of Paediatrics Policy Statement. Pediatrics

2003;111:113-115.

5. Calonge N. U.S. Preventive Services Task Force. Prevention of dental caries in preschool

children: Recommendations and rationale. Am J Prev Med 2004;26(4):326-329.

6. Tara ES, Steven MA. Prevention of dental disease. The role of the pediatrician. Pediatr Clin

North Am 2000;47:1021-1042.

7. American academy of pediatric dentistry (AAPD) reference manual 2009-2010.Pediatr

Dent 2009;31:1-302.

8. Sharma DS, Chauhan S, Kulkarni V, Reddy B, Khandelwal V, Gupta P. Awareness of oral

health among pediatricians:A preliminary study in Indore. Natl J Dent Sci Res 2012;1:1-6.

9. Shetty RM, Dixit UB. Paediatricians’ views on dental and oral health and treatment needs

in children.Oral Health Prev Dent 2011;9:315-322.

10. Valaitis R, Hesch R, Passarelli C, Sheehan D, Sinton J. A systematic review of the

relationship between breastfeeding and early childhood caries. Can J Public Health

2000;91:411-7.

11. Indira MD, Dhull KS, Nandlal B. Knowledge,attitude and practice towards infant oral

healthcare among the pediatricians of Mysore.Aquestionnaire survey.Int J Clin Pediatr

Dent 2015;8(3);211-214.

12. Gustafsson BE et al. The Vipeholm Dental Caries Study. Acta Odontol Scand

1954;11:232–364.

13. Harris R: Biology of the children of Hopewood House, Bowral, Australia. 4. Observations

on dental-caries experience extending over five years (1957–1961). J Dent Res

1963;42:1387–1399.

14. Stephan RM, Miller BF. A quantitative method for evaluating physical and chemical

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15. American Academy of Pediatric Dentistry. Policy on Dietary Recommendations for

Infants, Children, and Adolescents. Reference manual 2012 ;37: 56-58.

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17. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental

caries in children and adolescents. Cochrane Database Syst Rev. 2003;1:1-102.

18. Tiller S, Wilson K I, Gallagher J E. The dental health and dental service use of adults with

learning disabilities. Comm Dent Health 2001; 18: 167-171.

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2000;44(3):443-456.

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21. Neves BG, Pierro VS, Maia LC. Pediatricians’ perceptions of the use of sweetened medications

related to oral health. J Clin Pediatr Dent 2008;32(2):133-137.

 Figure 1. Distribution of study participants

100
90
80
70
Number of pediatricians

60
50
40
30
20
10
0
es es t t
al al en den
M e m is d si
F e Re
o rR io
r
ni n
Ju Se
 Variable Correct Incorrect Lack of Total
knowledge knowledge knowledge
N (%) N (%) N (%) N (%)
Dental caries 64 (62.7) 06 (5.9) 32 (31.4) 102 (100.0)
Dental plaque 44 (43.1) 04 (3.9) 54 (52.9) 102 (100.0)
Recommended age to start tooth 36 (35.3) 61 (59.8) 05 (4.9) 102 (100.0)
brushing in children
Recommended age for child’s first 55 (53.9) 46 (45.1) 1 (1.0) 102 (100.0)
dental visit
Bottle feeding at night 90 (88.2) 06 (5.9) 06 (5.9) 102 (100.0)
Correct age to start weaning 40 (39.2) 60 (58.8) 02 (2.0) 102 (100.0)
Frequency of tongue cleaning per day 85 (83.3) 15 (14.7) 02 (2.0) 102 (100.0)
Importance of dental treatment in 56 (54.9) 34 (33.3) 12 (11.8) 102 (100.0)
primary teeth
Critical PH of saliva at which 33 (32.4) 43 (42.2) 26 (25.5) 102 (100.0)
demineralization of tooth starts
Maximum recommended sugar 36 (35.3) 58 (56.9) 08 (7.8) 102 (100.0)
exposures per day for prevention of
dental caries
Medications causing gum enlargement 94 (92.2) 0 (0.0) 8 (7.8) 102 (100.0)

Table 1. Knowledge of Pediatricians about oral diseases and oral hygiene measures

Table 2. Knowledge of Pediatricians regarding use of fluoride and its role in dental caries prevention

Variable Correct Incorrect Lack of Total

knowledge knowledge knowledge
N (%) N (%) N (%) N (%)
Use of Fluoride toothpaste for 24 (23.5) 46 (45.1) 32 (31.4) 102 (100.0)
children
Amount of fluoride (ppm ) in 03 (2.9) 35 (34.3) 64 (62.7) 102 (100.0)
toothpaste recommended for
children
Role of fluoride in dental caries 64 (62.7) 16 (15.7) 22 (21.6) 102 (100.0)
prevention
Fluoride varnish for dental caries 15 (14.7) 02 (2.0) 85 (83.3) 102 (100.0)
prevention

Table 3. Attitude and Practices of Pediatricians towards oral health of children with special health
care needs (CSHCN)
 Variable Never Sometimes Often Always Total

N (%) N (%) N (%) N (%) N (%)

How often do they examine
2 (2.0) 51 (50.0) 32 (31.4.0) 17 (16.7) 102 (100.0)
CSHCN
Parents of CSHCN reporting to
16 (15.7) 56 (54.9) 26 (25.5) 4 (3.9) 102 (100.0)
them with dental problems
Oral health examination
performed by them during their 2 (2.0) 48 (47.1) 30 (29.4) 22 (21.6) 102 (100.0)
general /physical examination
Referrals by them to a dentist
5 (4.9) 53 (52.0) 19 (18.6) 25 (24.5) 102 (100.0)
for treatment of oral diseases
Advice given by them to
parents regarding cleaning of
29 (28.4) 38 (37.3) 17 (16.7) 18 (17.6) 102 (100.0)
teeth/tongue after consumption
of sugar containing medications