J Dent Educ. 70(5): 511-517 2006
© 2006 American Dental Education Association
Critical Issues in Dental Education |
Dental and Medical Students’ Knowledge and Opinions of Infant Oral Health
Mina H. Chung, D.D.S., M.S.;
Linda M. Kaste, D.D.S., Ph.D.;
Anne Koerber, D.D.S., Ph.D.;
Shahrbanoo Fadavi, D.D.S., M.S.;
Indru Punwani, D.D.S., M.S.D.
Key words: dental care for children, dental education, dental students, infant care, medical education, medical students, tooth eruption
Submitted for publication 01/05/06;
accepted 02/08/06
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Abstract
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Primary care providers’ involvement with and perceptions of the epidemic of early childhood caries could be related to attitudes and knowledge of the disease as well as to differences in discipline-based recommendations. A cross-sectional survey of demographics, opinions on infant oral health care visits and importance of infant oral health care, knowledge of tooth eruption, and knowledge of health care guidelines of the American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) was administered by several methods to first- and fourth-year dental and medical students at two University of Illinois campuses. Some expected variations were found among dental and medical students pertaining to perceptions and knowledge of infant oral health. Higher proportions of dental students responded correctly or considered the issues very important. However, Rockford medicine students were more likely to know when children should be weaned, yet less likely to agree with recommendations for time of first dental visit. Furthermore, fourth-year dental students were less likely than first-year dental students to give the recommended answer for age of first dental visit. Variances of opinions and basic knowledge of infant oral health of dental and medical students showed inconsistencies with desired outcomes of educational and clinical experiences. Further research is needed to understand the role of experience and other factors to effectively educate primary care providers in this area.
The surgeon general’s report on oral health in America states, "Dental caries (tooth decay) is the single most common chronic childhood disease—five times more common than asthma and seven times more common than hay fever" for children over age five.1 Numerous studies and national objectives corroborate dental caries as a significant health problem in preschool children in the United States,2–6 including the fact that dental needs do not drive dental care utilization for children.7 Local population groups have shown even greater problems; for example, more than 50 percent of children have been found to have tooth decay by the time they reach kindergarten.8 Caries rates among children are so high that, to achieve the Healthy People 2010 objectives, collaboration between the dental and medical communities is essential.
Until recently, the recommendations of pediatric and pediatric dental professional organizations concerning infant oral health evaluations differed. Since 1986, the American Academy of Pediatric Dentistry (AAPD) has recommended that the first dental visit occur within six months of the eruption of the first tooth and no later than twelve months of age.9 In contrast, the American Academy of Pediatrics (AAP) previously recommended the first dental visit by age three, but changed the guideline in 2003 to establishing a dental home by age one for children with caries risk.10 Another important policy issue has been the timing of weaning children from a bottle to a cup. This is an area where there is agreement; weaning by twelve months is recommended in the literature of both the AAPD and AAP.9,11–15
Confusion over the past discrepancies between the organizations’ policies could be a basis for variation in the practices of family practice physicians, pediatricians, general dentists, and pediatric dentists. The literature reveals differences in the understanding and practices of dentists16–19 and physicians20–26 regarding early childhood oral health—particularly the age at which infants should receive their first oral examination. Some concerns about dental utilization patterns have already been raised as a result of differences in policy recommendations.27
The lack of oral health education in medical school and residency curricula has been well documented.21–24 Physicians report not receiving sufficient instruction on oral health care.20–26 Our survey takes a step forward by examining baseline knowledge and opinions of medical and dental students during their formative health care professional education at this important time of policy development.
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Methods
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Five classes of dental and medical students were surveyed from the Chicago and Rockford campuses of the University of Illinois near the end of the spring 2003 semester. The student classes were sixty-five first-year dental students (D1), fifty-six fourth-year dental students (D4), 190 first-year medical students (M1), and 170 fourth-year medical students (M4), plus forty-two fourth-year medical students from the University of Illinois at Rockford (M4R), including the rural medicine program. The Rockford medical program had no separate first-year class.
Participating students completed a ten-question survey that included four sections: demographics (age, gender, type of student, and whether they have children); knowledge of tooth eruption; knowledge of the AAP and AAPD guidelines on bottle weaning;9,11,14,15 and opinions on infant oral health care visits and importance of infant oral health care. Each survey included a cover letter matched to the mailing, explaining the goals of the study, inclusion criteria, anonymity of the study, and the risks and benefits of participation. The study was reviewed and approved as exempt by the University of Illinois at Chicago (UIC) Institutional Review Board.
Data were collected through a series of contacts, using a variety of methods due to the varying accessibility of each class and requirements of the respective programs. Surveys were mailed to home addresses of first- and fourth-year UIC medical students via U.S. mail. To ensure maximum participation by medical students, three mailings were completed with one month between each. Surveys were sent via campus mail to first- and fourth-year dental students. The response rates were low for dental students after the first mailing. Therefore, on the second round, surveys were distributed to dental students during lecture classes. Finally, an additional campus mailing was conducted to encourage further participation by dental students. Surveys were sent once to the M4R class via email, and their responses were returned by email to the student affairs office, ensuring minimal disruption to the class and that the respondents would be anonymous to the researchers.
As appropriate, questions were scored as correct or incorrect based on the recommendations of the AAP and AAPD.9–15 Opinion questions were dichotomized as either "Very Important" or not. The unadjusted frequencies of correct or "Very Important" responses of the five classes were compared for each question using chi square analysis. In one case, the assumptions of the chi square test were not met, and likelihood ratio was used instead.
Logistic regression analyses were also performed for each question for comparison across the groups. The referent group was the M1 class. To adjust for possible confounding variables, age, having children, and gender were entered into the regression analyses, producing adjusted odds ratios (OR) with 95 percent confidence intervals (CI). The adjusted results are provided, but inclusion of the potential confounders did not alter the relationships of the student groups.
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Results
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The overall demographic distribution of respondents is shown in Table 1
. The overall response rate was 58 percent, with the highest response for D4 students (70 percent) and lowest response for M4 students (49 percent). The M1 students had the highest number of respondents (n=119), and the M4R students had the lowest (n=26). Participation by males and females was similar (
2, p>.05). The majority (62 percent) of respondents were in the age range of twenty-three to twenty-seven years. More fourth-year medical and dental students had children than other classes.
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Table 1. Demographic characteristics of respondents to infant oral health questionnaire at a midwestern university, 2003
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For the knowledge questions, students were asked to identify when professional organizations recommend weaning children from the bottle and when the first tooth erupts. Overall, fourth-year students were more likely to answer the knowledge questions correctly, with the exception of the M4R students on eruption (Table 2). All of the D4 students answered correctly on the average age of first tooth eruption. The M4R students had the highest percentage of correct responses on age for bottle weaning. These differences were sustained in the logistic regression (Table 3).
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Table 2. Correct responses and opinions to infant oral health questionnaire at a midwestern university, by medical and dental students’ status, 2003
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Table 3. Logistic regression of dental and medical students’ knowledge and o pinions to infant oral health questionnaire at a midwestern university, 2003
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Students were asked, "At what age have you been taught to recommend a child’s first dental visit?" Dental students were more likely to report they were taught the correct answer, with D4 students only 9 percent higher than D1 students (Table 2
). None of the D4 students reported that they were not taught about the first dental visit; however, 17 percent of D1 students reported they were not taught, along with high frequencies of the medical students at 79 percent of M1, 71 percent of M4, and 46 percent of M4R students (data not shown on table). The odds of reporting that they were taught that the first visit should be by age one year were significantly higher for dental students than for the medical students (Table 3).
Students were asked to respond to three opinion questions concerning the timing of the first dental visit (Table 2). Dental students were more likely than medical students to give the professionally recommended answer (six to twelve months) as their opinion about the best age for the first dental visit.9,11,14 D1 students were more likely than D4 students to give the professionally recommended answer, and the M4Rs were least likely of any of the groups. Dental students were more likely than medical students to rank both for the following as being very important: children seeing a dentist at an early age and being taught recommendations about a child’s first dental visit. All of the D1, D4, and M4R students chose either "very important" or "important" for these two questions; however, some medical students did not rank these issues as important: 11 percent for the M1 students and 14 percent for the M4 students (data not shown). For all three of these questions, a higher percentage of the M1 students responded favorably than did the M4 students. The relationships were maintained in the same direction in the logistic regression (Table 3).
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Discussion
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The overall results contained some surprises. First, first-year dental students were more likely than fourth-year dental students to rank the first dental visit as important, and second, the Rockford medical students were the most likely to know when children should be weaned from the bottle but the least likely to think that the first dental visit should occur at one year of age. In other respects, the results are as expected. Dental students were more likely than medical students to know when the first tooth erupts and were more likely to highly rate the importance of seeing a child early.
The curricula of the various programs were examined in order to understand some of the differences among the student groups. The differences between the dental and medical students are partly an expected result of the differing focus of the two professions and their different curricula.
The differences between the D1 and D4 students may be a reflection of greater clinical experience of the D4 students. If so, the clinical experiences in dental school may modify students’ beliefs and attitudes about infant oral care, but perhaps not in the desired direction as other investigators have reported.28,29 A study of college students yielded similar results in that increased experience with children was associated with the opinion that children should be seen at an age later than recommended for the first dental visit.29 In contrast, a study of dental students found that rotation through a young patient and preventive clinic increased the number of dental students who recommended a first dental visit before age one year from 3 percent to 30 percent.30 The current results confirm the prior findings that increased experience may not always lead to the desired result. If dental students’ clinical experiences tend to be with older children or with children who have few oral care needs, it may be that they get the impression that younger children do not have oral health problems. Perhaps they gain the impression that dental visits are too traumatic for either the child or the health care provider to handle.
The medical school curriculum at the University of Illinois at Chicago did not incorporate any formal training on infant oral health, and there is only a small possibility that the pediatric medicine clerkship would have provided such training.31 A review of the curriculum and objectives of pediatrics and family medicine clerkships found no specific mention of competency on infant oral health. However, there is a competency listed for knowledge of preventive pediatrics and anticipatory guidance.32,33 The medical students’ responses to this survey reflect the students’ inadequate knowledge of infant oral care. These findings echo previous studies of physicians who reported they did not receive adequate education concerning oral health.20–26
The training of the Rockford medical students differed from the main program medical students because their program initiated a longitudinal primary care experience in the second year. This primary care experience continued through the third and fourth years, during which each student followed the health of approximately seventy-five families. Their experience was highly focused on anticipatory guidance, counseling, and preventive health.34 Similarly, rural pediatricians have shown a tendency to provide earlier preventive oral health than the urban pediatricians.23,24,35 The Rockford medical students were more knowledgeable than any of the other groups (including the dental students) of the professional groups’ weaning recommendations and more likely than the other medical students to consider preventive oral health important. Unfortunately, in spite of their greater knowledge and experience, Rockford medical students still felt a dentist should first see children at a later age than recommended.
Several collaborative programs have been initiated between dental and medical schools that show positive influence on physicians; examples are at the University of Virginia and University of Rochester Medical Center.36–43 Some schools (for example, the University of British Columbia,36 the College of Physicians and Surgeons at Columbia University,37 and Harvard University39) have combined basic science courses for dental and medical students, which could improve the opportunity for physicians to acquire didactic knowledge about infant oral health care.
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Study Limitations
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The differential response rates and modes of collection for dental and medical students may be a concern in this study, although respectable response rates were achieved in all groups. The most likely response bias is that those students who had more confidence in their knowledge were more likely to respond; this suggests that the true results may have shown lower levels of infant oral knowledge among students. It is possible that the Rockford medical students may have answered more thoughtfully, since the emailed responses went through the medical college administrative offices. The differences between years may be due to cohort differences instead of differences in educational level. In addition, influences from unmeasured variations in class composition and background of students may confound the findings. Since the study surveyed students from one institution, the results may not be generalizable to the full body of dental and medical students in the United States. In spite of these difficulties, the differences found among the groups are likely to approximate the true differences.
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Implications for Future Research
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With the recent movement of the AAP to reinforce the AAPD guidelines for the timing of the first dental visit, the much-needed attention toward an early intervention approach is slowly making its way into the medical and general community. Future studies should look at the influence of the new guidelines and to monitor changes in infant oral health knowledge and practices concerning first dental visit and weaning practices among the dental, medical, and general communities. To assess the impact of the integration of infant oral health care guidelines into the dental and medical curricula, studies are needed to track oral health status among children in various population groups.
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Conclusion
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This study suggests that experience may not reinforce the recommendations of professional organizations such as the AAPD and AAP regarding infant oral health evaluations. Programs designed for the education of dentists and physicians should find ways to introduce best practices in infant oral health to counteract the possibility of incomplete information received from limited clinical experience or other aspects of the training programs.
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Acknowledgments
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We would like to thank Dr. James Mendez, Dean of Student Affairs, University of Illinois at Chicago College of Medicine; Dr. Michael Glasser, Associate Dean, University of Illinois at Rockford; Ms. Kathy Norman, Director of Student and Alumni Programs, University of Illinois at Rockford; and Ms. Nancy Taylor, Assistant to the Associate Dean, University of Illinois at Chicago College of Dentistry, for their assistance in this study.
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Footnotes
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Dr. Chung is Clinical Assistant Professor, Dr. Kaste is Associate Professor, Dr. Koerber is Assistant Professor, Dr. Fadavi is Professor, and Dr. Punwani is Professor and Department Head—all in the Department of Pediatric Dentistry, College of Dentistry, University of Illinois at Chicago. Direct correspondence to Dr. Mina H. Chung, University of Illinois at Chicago College of Dentistry, Department of Pediatric Dentistry, 801 South Paulina Street, MC 850, Chicago, IL 60612; 312-996-7531 phone; 312-996-1981 fax; mchung4{at}uic.edu. Reprints will not be available.
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Abstract
Methods
