The World Health Organisation’s first goal for oral health in 2020 is to minimize the impact of oral diseases on health and psychosocial development, as well as to emphasize the promotion of oral health and the reduction of oral diseases29; cooperation between healthcare providers (i.e., GMPs; paediatricians; pedodontists) to improve the child's oral health surely would aid in attaining such a goal.
Despite all the efforts made to reduce caries prevalence in Saudi children, it seems nothing is particularly effective thus far; this is likely spurred by the fact that children are typically not seen early enough by dentists within our community compared to paediatricians and General Practitioners27. A minimal number of studies have viewed this aspect alongside paediatricians’ attitudes towards pediatric oral health, none similar to the present study considering the referral patterns.
The current study sheds light on a crucial health care issue: the degree of knowledge and preventive awareness present within GMPs and paediatricians in terms of children’s dental diseases. Such an understanding would be guaranteed to wield a positive influence over the overall healthcare provided to children.
The main finding of the current study is the absence of an adequate amount of dental knowledge; this may be a primary barrier to effective child dental referral, oral health knowledge is not currently sufficient enough for effective referral (only 4.4% of physicians answered all knowledge questions correctly, the percent of correct mean knowledge score being 2.95%). These results correlate with those founded in a study conducted by HJ Sabbagh et al. in Jeddah25, Saudi Arabia. Alshunaiber et al. similarly reported an acceptable level of knowledge amongst their sample of paediatricians in Riyadh, Saudi Arabia, despite there being a discrepancy between their practices27. In Turkey, Sezer et al. found there to be a lack of dental knowledge, only 13.9% of the sample stating that they would refer a one-year-old or younger patient to be seen by a dentist30; conversely, an Indian sample was founded to possess a higher level of knowledge and willingness to provide oral health advice31.
Adequate children’s oral health knowledge is of high importance when it comes to the prevention of dental caries, as well as its associated adverse effects27; it is on this note that Parakash et al. have reported the importance of caregivers’ knowledge and the vital influence of this knowledge on children’s oral health.21
The knowledge score was not significantly impacted by discrepancies between gender or years of experience; however, the results were impacted by differences between GMPs and paediatricians. This finding correlates with that of Nassif et al., who conducted their study in Lebanon32.
The basic knowledge needed for referral should be adequate, particularly amongst specialised physicians, and yet the presence of several glitches and gaps amongst physicians’ knowledge within the current study would have impacted their referral practice, particularly amongst GMPs. This could also be influenced by the wide spectrum of treatment and management they provide in a shortage of time.
Respondents were asked to report the likelihood of performing some oral health related activities during child well visit, and the majority of the paediatricians and GMPs (83.7%) stated that the examination of the oral cavity and teeth would likely be done; indeed, similar findings were reported within previous studies on the topic 21,25,33. The majority of the sample additionally mentioned that they would be more likely to provide dietary counselling to parents (as recommended by the American Academy of Paediatrics, which is considered as an essential part of general health counselling); furthermore, a similarly high percentage was founded regarding advising the parents about dental visits, demonstrating the fact that paediatricians and general medical practitioners agreed upon the importance of oral health education and guidance during child visits. Over one third of the respondents (36%) were willing to incorporate fluoride application in their practice. In a study conducted by Ditto et al. (2009), reporting only 7% of physicians believing the application of fluoride to be part of a sufficient childcare visit23. Lack of knowledge on preventive dentistry, interest, and time—as well as the cost of the dental materials—may additionally act as a contributing factor to such findings, those findings suggesting a lack of awareness on the fluoride positive effects34.
Dental pain and oral/facial trauma/swelling cases were always referred to pediatric dentists, thus reflecting the concern of paediatricians and GMPs regarding any visible problems; to a lesser extent (71%), children with dental caries would be referred always and/or often. Unfortunately, this is considered insufficient in preventing the consequences reported by Kagihara et al. (2009), who stated that when dental caries is left untreated, pain, bacteraemia and high treatment costs are anticipated; this can additionally impact the growth and development of the child’s speech, leading to premature tooth loss and compromised chewing and self-esteem35.
Surprisingly, children with chronic medical conditions, planned operations, or necessary cancer therapy possess the least chances of referral; this could be ascribed to the participants’ limited knowledge and awareness on the relevance of such medical problems to dental health. This result correlates with those of a number of previous studies whereby the oral-medical connection was not very clear to participants.23,34
It was reported that barriers to successful referral were mentioned by more than 50% of the respondents in a previous study, a slightly higher percentage (57%) being detected amongst the respondents within the current study23.
Perhaps at the heart of the reluctance to examine children in terms of a dental examination; lies in the fact that the responders felt it was difficult to refer onwards to public and private dental clinics. In this regard, we can confirm that their concerns are well-founded: previous studies have shown that clinicians are more likely to refer children if they report confidence with the referral environment36.
In Saudi Arabia—in a similar way to other countries around the world—, public dental practices possess long waiting lists, thus adding to the already present complexity of access already caused by the dental service availability issue37,38. This fact makes the collaboration with medical general practitioners and paediatricians even more essential; undeniably, we can see that early referral, detection of dental problems, and prevention should be the primary aim.
Considering nearly around half of the sample claimed they had not received any oral health information during their studies—reflecting their care about dental health, such results correlating with those of Prakash et al.21, the majority of paediatricians and GMPs supported the idea of adding oral health rotations to the pediatric residency curriculum; importantly, the existing literature suggests that medical healthcare providers generally possess a positive attitude towards the importance of oral health in children, and express willingness to perform oral health activities21,28,39.
Oral health education has, traditionally been rather far down on the priority scale within medical students/paediatricians’ postgraduate educations globally37,38; in fact, oral health has mostly not been an element of the purview for medical practitioners in a strange disconnect from the rest of health and development40. Thus, in order to address this knowledge and practice gap, oral health education is vital across the health professions; paediatricians do not stand alone in their lack of comfort in addressing oral health issues41. Several medical school surveys have similarly showcased a lack of comprehensive instruction on dental topics, as well as an absence of standardised learning objectives, teaching methodology, and assessment42–44.
It has been suggested that oral health and dental care modules are incorporated in the curriculum for the pediatric training of general paediatrics; further, a rotation with pediatric dental professionals within a hospital/community could additionally provide postgraduate specialist trainees with practical skills in assessing children’s oral health and the potential risk of dental diseases24.
Notably, conferences, scientific journals, and continuous medical educations were the least common sources of dental information amongst the respondents, whilst a significant number of physicians (50.3%) received their information from combined sources (e.g., media; the Internet; personal communications; continued education; conferences; scientific journals), which would significantly impact their knowledge levels.
A total of 80% of young children within Saudi Arabia have caries in their primary teeth15; healthcare team members’ efforts—including those of paediatricians—should be coordinated to control such a preventable disease.
Referring to the limitations of the present study, the modest response rate is one limitation that has the potential to impact the generalisability of the findings; the sample was a convenient one, and so could potentially result in selection bias. Notably, a difficulty that arose during the data collection phase was that of the long waiting time needed to gain approval from each hospital in order to conduct a survey amongst the paediatricians working there. A final issue is that of the answers all being self-administered, lending the way to them being misleading and/or inaccurate in occasional cases27.