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J Dent Educ. 71(11): 1420-1427 2007
© 2007 American Dental Education Association
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Critical Issues in Dental Education

Dental Students’ Knowledge, Attitudes, and Intended Behaviors Regarding Caries Risk Assessment: Impact of Years of Education and Patient Age

Sophia H. Calderón, B.A.; Paul Gilbert, Sc.M.; Rasika N. Zeff, D.D.S.; Stuart A. Gansky, Dr.P.H.; John D.B. Featherstone, M.Sc., Ph.D.; Jane A. Weintraub, D.D.S., M.P.H.; Barbara Gerbert, Ph.D.

Key words: caries risk assessment, prevention, dental education, dental students, dental caries

Submitted for publication 03/30/07; accepted 08/01/07


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Dental caries remains the single most common chronic childhood disease; without intervention, the prevalence and severity of caries increase into adulthood. Dental schools have begun to integrate caries risk assessment (CRA) and prevention counseling into the curriculum. We sought to assess the knowledge, attitudes, and intended behaviors of dental students regarding CRA and prevention counseling with children and adults. We also examined the extent to which these findings were influenced by the years of instruction that students received on these topics. We conducted a cross-sectional survey of dental students at the University of California, San Francisco. All first-year (D1) through fourth-year (D4) students were eligible to participate. Of the 322 eligible students, 290 (90 percent) participated. D4 students correctly answered a mean of 70.4 percent of the knowledge-based questions on CRA; the mean score among D1 students was 50.4 percent. Whereas 95 percent of D4 students identified themselves as confident in their ability to assess adult patients for caries risk, only 68 percent had such confidence with patients less than five years. To effectively prevent early childhood caries, dental schools should provide students with the skills necessary to be confident and willing to perform CRA and prevention counseling for all age groups.

There has been much progress over the past several decades in the prevention of dental caries, due largely to the presence of fluoride in drinking water, in dentifrices, and in regular in-office treatments.1,2 Even with the utilization of fluoride, however, dental caries remains the single most common chronic childhood disease, five times more common than asthma and seven times more common than hay fever.3 Moreover, without intervention, the prevalence and severity of caries increase as the child gets older.4–7

Beyond oral health, the social and financial impact of caries is significant. More than 51 million school hours are lost each year in the United States to dental-related illness.8 This figure suggests an equally striking number of work days missed by parents due to their children’s dental illness. Dental caries can also affect food choices, the ability to eat, appearance, and communication, thereby decreasing the quality of life for both children and adults.9

It has been proposed that dental clinicians redirect their management of dental caries from a "surgical approach" to a "medical prevention strategy."10 In 2002, a group of dental caries experts produced a consensus statement, entitled Caries Management by Risk Assessment (CAMBRA), regarding the practice of caries prevention, risk assessment, and management.11 CAMBRA included two tools for caries risk assessment (CRA) (one form for children less than six years of age and one form for adults and children six years of age or greater) as well as guidelines for implementation. Although these recommendations were intended to be a "work in progress subject to improvement and modification as new information becomes available,"11 their immediate implementation was encouraged.

Given the growing epidemic of early childhood caries (ECC) in the United States,11 CRA in children has played a prominent role in the prevention of dental caries. Because dental caries is a bacterially based transmissible disease, caries prevention efforts should begin at a young age to decrease early colonization.12–15 Accordingly, with the support of the American Academy of Pediatrics (AAP), the American Academy of Pediatric Dentistry (AAPD) developed recommendations for performing CRA and preventive strategies.16 One of the principal AAPD recommendations was that every infant should receive an oral health risk assessment from a primary care provider by six months of age. If the infant is assessed to be high risk, then a dental home (a specialized primary dental care provider) should be established. Additionally, it was recommended that a dental home should be established by twelve months of age for all children regardless of their risk status.

Dental schools have begun to integrate CRA and disease management into didactic and clinical education. One survey of dental schools in the United States found that thirty-four out of forty-two responding schools reported having a formal caries risk education program for predoctoral students.17 For many schools, CRA is a part of the predoctoral didactic curriculum,18–21 and some have incorporated it into students’ clinical experience.20–22

Preliminary studies have indicated the benefits of CRA education programs. In a pre- and post-implementation study, Wandera et al. found that students who received education in infant oral health care felt better prepared to evaluate caries risk than those who had not received the curriculum.23 In a recent article, 80 percent of dental students indicated they were likely to use the AAPD’s caries assessment tool (CAT) in their clinical practice.24–26

Given the importance of prevention and early treatment of dental caries and the recent efforts at implementing such education in the curriculum of dental schools, we sought to assess the knowledge, attitudes, and intended behaviors of dental students regarding CRA and caries prevention counseling with children and adults. Furthermore, we sought to examine the extent to which these findings were influenced by the years of instruction that dental students had received on CRA and prevention counseling. The School of Dentistry at the University of California, San Francisco (UCSF) provided us with the opportunity to conduct a natural experiment within one school environment. At UCSF, CRA forms and protocols consistent with the CAMBRA consensus statement were introduced into the predoctoral didactic curriculum and teaching clinics in 2003.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
After receiving the approval of the UCSF institutional review board for all study procedures, we conducted a cross-sectional survey of UCSF dental students in the summer and fall quarters of 2005. All first-year (D1) through fourth-year (D4) dental students were eligible to participate. All classes were surveyed at the beginning of their relevant academic year, allowing us to measure differences among the classes based on educational experiences. We surveyed the first- and second-year dental classes in the fall quarter of 2005; D3 and D4 students were surveyed in the summer quarter of 2005 (their class year began in the summer). Students were recruited at the beginning of a class session by one of the researchers (RZ), who gave an explanation of the study, invited students to participate, and answered questions. Interested dental students provided written informed consent and completed the survey during their class session. Students were assured that lack of participation would not influence their course grades. Each participant was compensated with a $10 gift card from a national coffee retailer.

The CRA curriculum at UCSF has been described in detail elsewhere.26 Caries risk assessment and prevention counseling were introduced in the first-year preclinical laboratory, where dental students learn the mechanisms of remineralization and demineralization, fluoride actions, the roles of saliva, and the fundamental biology of the caries process. In the second year, students participate in a "dental sciences" course, a specific lecture series in which they learn the principles of CRA and caries management by therapeutic measures. This leads to instruction on the use of the CRA forms used in the clinic and the written patient recommendations. In the third year, dental students begin clinical rotations in which they are expected to complete CRA forms for every patient requiring new and periodic oral examinations, excluding for pediatric patients five years old or less. These procedures continue through the fourth year in the clinics. In addition, training on prevention counseling includes lectures on oral hygiene instruction, the composition of preventive products, and the appropriate products to recommend for the various caries risk levels (low, moderate, or high). Frequency of ingestion of fermentable carbohydrates is emphasized as the key dietary modification to reduce caries risk. These topics are reinforced in the clinic during the delivery of the CRA procedure and the patient recommendations that follow, using written instructions and checklists. Also, faculty receive training in caries risk assessment on a regular, repeating basis.

For this study, all participants completed a twenty-six-item written survey regarding CRA and prevention counseling that assessed knowledge (twelve questions, including one assessing confidence in knowledge), attitudes (seven questions, including four assessing perceived confidence, operationalized as "feeling competent"), and intention to provide certain dental care services (five questions) (Figure 1Go). Two questions collected respondents’ demographic characteristics. Response options for most questions were true/false or multiple choice. Confidence was measured using a ten-point scale. A four-point Lik-ert scale was used for the seven attitude questions (strongly disagree, disagree, agree, strongly agree). The absence of a neutral midpoint forced respondents to express an opinion. We also collected demographic information from the students, including gender, class year, and dental career plans.


Figure 1
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  		Figure 1. Selected items from assessment tool

 
Our survey items were adapted from work published by dental experts in the Journal of the California Dental Association.11 We pilot-tested an initial survey with pediatric dental residents and postdoctoral students in the spring and summer of 2005 at the UCSF School of Dentistry. Based on the feedback from these pilot participants, the survey was modified for improved clarity and comprehension.

Generalized estimated equation (GEE) models with logit link, binomial variance, and exchangeable correlation assessed the relationship of positive attitudes (agree or strongly agree) with class year, age of patients, and the interaction between class year and age of patients. Step-down Bonferroni (Bonferroni-Holm) corrections were used for pairwise comparisons to a reference group (adults and D4 students). GEE models also assessed willingness to provide services, and Spearman rank correlations assessed associations among ordinally scaled variables, including self-rated confidence with percent correct. Ordered trends by class year (D1<D2<D3<D4) were assessed with 1 d.f. tests.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Of the 322 eligible UCSF dental students, 290 (90 percent) completed the survey. Among the four class years, surveys were completed by eighty of eighty-one (99 percent) D1 students, seventy-two of eighty-one (89 percent) D2 students, sixty-three of eighty-two (77 percent) D3 students, and seventy-five of seventy-nine (95 percent) D4 students. Sixty-six percent of the respondents were female. Sixty-five percent of the dental students planned to practice general dentistry upon graduation. All surveys were eligible and utilized for analyses.

By the beginning of their fourth year in dental school, students correctly answered a mean of 70.4 percent of the eleven knowledge-based questions about CRA, and their confidence concerning their answers was a mean of 7.0 on a ten-point scale with higher ratings indicating more confidence (Figure 2Go). Dental students’ accuracy in answering the knowledge-based CRA questions was significantly positively associated with years of instruction, demonstrating a linear trend (D1<D2<D3<D4). The mean score among students entering their first year was 50.4 percent. Students’ confidence concerning their answers mirrored their knowledge; entering dental students had a mean score of 4.0.


Figure 2
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  		Figure 2. Confidence and knowledge score comparison by year in school (N=290)

 
Students’ Confidence in Performing CRA
Ninety-five percent of D4 students identified themselves as confident in their ability to assess adult patients for caries risk (Figure 3Go); the same percent of D4 students felt such confidence with patients twelve to seventeen years old. By comparison, only 68 percent of D4 students felt confident assessing caries risk in patients less than five years of age. Eighty-five percent of D4 students felt confident assessing caries risk in patients five to eleven years old. Similar to these findings were the numbers of D4 students who responded that they felt confident in their ability to provide prevention counseling to each of the four patient age groups. Whereas 95 percent of students felt confident providing prevention counseling to adults, only 75 percent of students felt such confidence with patients less than five years old.


Figure 3
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  		Figure 3. Perceived confidence in performing caries risk assessment, by patient age group (N=290)

 
There was a significant positive association between years of instruction and perceived confidence in assessing caries risk. The impact of patient age group on dental students’ perceived confidence in performing CRA became more noticeable among students in higher class years. Among the eighty students entering their first year, the percent who felt confident in their ability to assess caries risk in adults (24 percent) was only slightly higher than for CRA in children less than five years old (19 percent). The discrepancy between these two percentages grew with years of instruction. In all class years, the percentage of students who felt confident performing CRA for patients between twelve and seventeen years of age closely resembled the percentage of students who indicated confidence performing CRA for adults.

Though less pronounced than that between years of instruction and perceived confidence in performing CRA, a positive association existed between years of instruction and dental students’ perceived confidence in providing preventive counseling (p=0.0007). Compared to students in their fourth year, fewer D1 students felt confident in their ability to provide preventive counseling to patients in each age group. In all class years, more students felt confident providing preventive counseling to adults and patients twelve to seventeen years old than to the younger age groups. A significant interaction between class year and patient age group also existed, as D3 students had the largest increase in confidence for patients at least twelve years old.

Students’ Intent to Provide CRA
When asked about the age groups to which they were willing to provide CRA, more D4 students (91 percent) indicated adults than any other patient age group. For the questions measuring intent, adults were defined as those eighteen to sixty-five years old. Slightly fewer D4 students were willing to provide CRA to twelve to seventeen year olds (88 percent). Only 60 percent of D4 students were willing to provide CRA to patients less than five years old. The percent of D4 students who planned to provide prevention counseling demonstrated a similar positive linear association concerning patient age groups: more D4 students indicated adults and twelve to seventeen year olds (87 percent for each) than the younger age groups. When asked about the age groups to which they were planning to provide a dental home, defined in the survey as "comprehensive oral health care including acute care and preventive services," more D4 students answered adults (88 percent) than younger patients. Only 36 percent of D4 students intended to provide a dental home to children less than five.

Unlike their perceived confidence, dental students’ intended behavior remained mostly unchanged by years of instruction. The percentages of students willing to provide CRA, prevention counseling, and a dental home were similar in each class year; any measured change did not reach statistical significance. In contrast, a positive linear association existed between patient age group and the percent of students who felt willing to provide each service. This association was evident in each class year.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
We found that UCSF dental students’ knowledge and attitudes regarding CRA and prevention counseling are positively influenced by their years of instruction, while their intended behaviors remain mostly unchanged. Though dental students entering their fourth year score significantly higher than the entering students on the knowledge-based questions, D4 students still have substantial room for improvement in their knowledge of CRA and prevention counseling. Furthermore, their moderate level of confidence concerning their answers indicates that D4 students acknowledge their insufficient knowledge. Nonetheless, D4 students’ knowledge may continue to improve in their last year before graduation.

Our findings indicate that the age of the patient significantly influences UCSF dental students’ attitudes and intended behaviors regarding CRA and prevention counseling. Fewer dental students feel confident performing CRA and prevention counseling with younger patient age groups (particularly children less than five years old, but also those between ages five and eleven) than with adults; we found the same findings for their willingness to provide such services. Students’ answers to most of the survey items, and particularly those assessing confidence, suggest that they view patients between twelve and seventeen years of age similarly to adults.

In light of the importance of early caries prevention efforts, our findings concerning younger patients are especially noteworthy. Our data can be partially attributed to the pediatric component of the predoctoral curriculum at UCSF, which focuses on the treatment of children six years and older; the treatment of children below six years is primarily the province of the pediatric dentistry residents. Still, placing early childhood caries prevention exclusively in the realm of pediatric dentistry seems particularly problematic given that the number of pediatric dentists is inadequate.27 In California alone, the California Society of Pediatric Dentistry reports only 501 active members who are pediatric dentists, which is certainly insufficient to meet the dental needs of the 2.8 million children under the age of six living in the state.28 Perhaps a more feasible prevention strategy would be to heighten general dentists’ and dental hygienists’ comfort with CRA and prevention counseling with young children. Implementing such a strategy should include incorporating these topics into the predoctoral dentistry curriculum and placing more emphasis on them.

There are several limitations inherent in our findings. First, in order to make comparisons between years of instruction, we assumed that each cohort of dental students was similarly predisposed to CRA education. Second, we assumed that the amount of CRA education was consistent throughout each year of instruction (first year, second year, etc.). Third, due to the cross-sectional nature of our analysis, we were only able to detect associations between variables; we cannot make any statements about causal relationships. Finally, we used data from only one dental school to reduce the possible confounding effect of differences in dental curricula and teaching styles; however, this also limits the generalizability of our findings.

We acknowledge that there are many topics in the dental school curriculum that require in-depth instruction and that expertise in all disciplines is unrealistic, especially in a university that offers a pediatric residency and other postdoctoral programs. Due to the overwhelming need for early caries prevention, however, dental schools should provide students with the skills necessary to feel confident and willing to perform CRA and prevention counseling for all age groups. Our findings have helped identify a gap in the UCSF School of Dentistry’s curriculum. The shortage of pediatric dentists necessary to meet the needs of all young children at risk of early childhood caries means that UCSF dental students need more training in behavioral management of young children as well as in health promotion and anticipatory guidance to provide their parents with needed oral health information.

The UCSF predoctoral curriculum was recently revamped and continues to evolve. As we learn the limitations of the current curriculum, we hope that more modifications will occur to place more emphasis on CRA, prevention, early detection, and treatment. Other schools may want to use similar evaluation tools to help assess the impact of their educational messages on students’ intended practice behaviors. The previous success of CRA education programs further supports their incorporation on a national level into dental education, an important step toward significantly improving the dental health of the hundreds of thousands of Americans who are at risk for dental caries.


   Acknowledgments
 
We thank the students who participated in the survey. This research was supported in part by cooperative agreement US DHHS NIH/NIDCR and NCMHD U54DE14251.


   Footnotes
 
Ms. Calderón is Staff Research Associate; Mr. Gilbert is Senior Research Associate; Dr. Zeff is a former Pediatric Dental Resident; Dr. Gansky is Associate Professor; and Dr. Featherstone, Dr. Weintraub, and Dr. Gerbert are Professors—all in the Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco. Direct correspondence and requests for reprints to Dr. Barbara Gerbert, Division of Behavioral Sciences, Professionalism, and Ethics, School of Dentistry, University of California, San Francisco, 350 Parnassus Avenue, Suite 905, San Francisco, CA 94117; 415-502-7283 phone; 415-502-7314 fax; barbara.gerbert{at}ucsf.edu.

This research was supported in part by US DHHS NIH/NIDCR U54DE014251.


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