Dentistry, Faculty of
DSpace
UBCV
Abushanan, AlWaleed
Master of Science - MSc
University of British Columbia
Objectives: To evaluate family medicine residency curricula content pertaining to, and residents’ training in, infants’ oral health in Canada. Methods: Two brief self-administered online surveys were developed using Research Electronic Data Capture (REDCap). One survey targeted all the 17 Canadian family medicine training program directors, and another target the currently enrolled residents within these programs. Questions focused on training, attitudes and practices towards infant oral health. Statistical tests were performed using SPSS version 22 with a confidence interval of 95% and a significance level of 0.05. Results: A total of 11 family medicine directors and 155 family medicine residents responded to the survey. The vast majority 90% (N=10) of the directors indicated that clinical oral health screening was not incorporated into the curriculum, particularly around early childhood caries. Over half the residents (53%, n=82) reported that they did not feel their training was adequate to identify dental caries in children. As 41% (n=63) of the residents described the quality of their training in oral health-related topics during their residency to be poor, more than two thirds (62%, n=96) of them seldom performed a visual examination of the children’s teeth. Although family medicine residents felt that physicians have an important role in promoting oral health among infants and toddlers, the majority (72%, n=112) of them reported lack of knowledge and training as the main barriers to performing oral health-related practices. Conclusion: Most of the Family Physicians training programs in Canada do not include infant oral health screening in their curriculum. While the majority of family medicine residents felt that physicians have an important role in promoting oral health amongst children, the reported lack of knowledge and training were hindering them from performing various oral health-related practices.
Family Medicine Residents’ Oral Health-Related Training, Attitudes, and Practices Towards Infant Oral Health by AlWaleed Abushanan BDS, Riyadh Colleges of Dentistry and Pharmacy, 2012 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF Master of Science in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Craniofacial Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) December 2018 © AlWaleed Abushanan, 2018 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled: Family Medicine Residents’ Oral Health-Related Training, Attitudes, and Practices Towards Infant Oral Health Submitted by AlWaleed Abushanan in partial fulfillment of the requirements for the degree of Master of Science in Craniofacial science Examining Committee: Mario Brondani Supervisor Quynh Doan Supervisory Committee Member Kavita Mathu-Muju Supervisory Committee Member Leeann Donnelly Additional Examiner iii Abstract Objectives: To evaluate family medicine residency curricula content pertaining to, and residents’ training in, infants’ oral health in Canada. Methods: Two brief self-administered online surveys were developed using Research Electronic Data Capture (REDCap). One survey targeted all the 17 Canadian family medicine training program directors, and another target the currently enrolled residents within these programs. Questions focused on training, attitudes and practices towards infant oral health. Statistical tests were performed using SPSS version 22 with a confidence interval of 95% and a significance level of 0.05. Results: A total of 11 family medicine directors and 155 family medicine residents responded to the survey. The vast majority 90% (N=10) of the directors indicated that clinical oral health screening was not incorporated into the curriculum, particularly around early childhood caries. Over half the residents (53%, n=82) reported that they did not feel their training was adequate to identify dental caries in children. As 41% (n=63) of the residents described the quality of their training in oral health-related topics during their residency to be poor, more than two thirds (62%, n=96) of them seldom performed a visual examination of the children’s teeth. Although family medicine residents felt that physicians have an important role in promoting oral health among infants and toddlers, the majority (72%, n=112) of them reported lack of knowledge and training as the main barriers to performing oral health-related practices. Conclusion: Most of the Family Physicians training programs in Canada do not include infant iv oral health screening in their curriculum. While the majority of family medicine residents felt that physicians have an important role in promoting oral health amongst children, the reported lack of knowledge and training were hindering them from performing various oral health-related practices. v Lay Summary Early childhood caries can have serious effects on children’s quality of life, their families, and the healthcare system. Early detection and prevention of this disease aims to reduce its incidence and negative consequences. Integrating oral health into the primary care setting, particularly within family physician training programs, can improve a child’s quality of life as these professionals have the opportunity to see children at an early age more frequently than a dental provider. This study aimed to assess the current status of the oral health curriculum in family medicine training programs in Canada, as well as the attitudes and practices of family medicine trainees towards early childhood caries and infants’ oral health. Results showed that most Family Physicians training programs in Canada did not include infant oral health discussion in their curriculum, although the majority of family medicine residents felt that physicians have an important role in promoting oral health amongst children. vi Preface This thesis is an original intellectual product of author A. Abushanan. Ethical approval for this study was granted by The University of British Columbia Behavioural Research Ethics Board (BREB) (Certificate number H17-00453) and the University of Alberta Research Ethics Board (REB) (Certificate number Pro00085423). vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ................................................................................................................................ v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables .................................................................................................................................. ix List of Figures ................................................................................................................................ x List of Abbreviations ................................................................................................................... xi Acknowledgements ..................................................................................................................... xii Dedication ................................................................................................................................... xiii Chapter 1: Introduction ..........................................................................................................................1 1.1 Early Childhood Caries ............................................................................................................1 1.2 Use of Fluoride in Caries Prevention .......................................................................................2 1.3 Access to Oral Health Care and Primary Care .........................................................................3 1.4 Oral Health Knowledge of Health Care Professionals .............................................................5 1.5 Objectives .................................................................................................................................9 1.6 Research Questions ..................................................................................................................9 1.7 Hypotheses .............................................................................................................................10 Chapter 2: Materials and Methods ......................................................................................................11 2.1 Research Design and Methods ...............................................................................................11 2.2 Study Procedures ....................................................................................................................12 2.2 Directros' Survey ................................................................................................... 12 viii 2.2 Residents' Survey .................................................................................................. 13 2.3 Data Collection and analysis ..................................................................................................14 Chapter 3: Results .................................................................................................................................17 3.1 Descriptive Statistics ..............................................................................................................17 3.1.1 Family Medicine Oral Health Curriculum and Training ...................................... 17 3.1.2 Residents’ Demographics and Practice Characteristics ........................................ 20 3.1.3 Oral Health-Related Practices of Family Medicine Residents ............................. 22 3.1.4 Residents' Attitudes Towards Oral Health Topics ................................................ 24 3.1.5 Residents' Oral Health-Related Training and Education ...................................... 26 3.2 Inferential Statistics ................................................................................................................28 Chapter 4: Discussion, future directions and conclusions .................................................................38 Bibliography ................................................................................................................................ 44 Appendices ................................................................................................................................... 48 Appendix A – Rourke Baby Record ...................................................................................48 Appendix B – AAP Oral Health Risk Assessment Tool ....................................................56 Appendix C – AAP Oral Health Self Management Goals ................................................59 Appendix D – Pediatric Dental Health Screening Guide ................................................48 Appendix E – Directors’ Survey .........................................................................................63 Appendix F – Residents’ Survey .........................................................................................65 Appendix G – Email Script ..................................................................................................68 ix List of Tables Table 1 – Characteristics of the residents ..................................................................................... 21 Table 2 – Family medicine residents’ oral health-related practices ............................................. 23 Table 3 – Family medicine residents’ attitudes towards oral health-related statements ............... 25 Table 4 – Association between residents with different attitudes about their role in promoting oral health and performing oral health-related practices .............................................................. 31 Table 5 – Association between physicians with different attitudes about the importance of primary dentition and oral health-related practices ...................................................................... 32 Table 6 – Association between physicians who observed and did not observe caries and oral health-related practices ................................................................................................................. 33 Table 7 – Association between physicians in different years of training and their oral health-related practices ............................................................................................................................ 34 Table 8 – Association between residents’ perceived barriers and their oral health-related practices ........................................................................................................................................ 35 Table 9 – Multivariate logistic regression model of variables associated with dental assessment36 Table 10– Multivariate logistic regression model of variables associated with oral health counselling .................................................................................................................................... 37 x List of Figures Figure 1 – Oral health-related topics included in family medicine curriculum ............................ 18 Figure 2 – Oral health-related practices formally taught in family medicine curriculum ............ 19 Figure 3 – Family medicine residents’ quality of training in oral health-related topics ............... 27 Figure 4 – Oral health-related topics the family medicine residents would like to know more about .............................................................................................................................................. 27 xi List of Abbreviations AAP: American Academy of Pediatrics AAPD: American Academy of Pediatric Dentistry BCCHR: British Columbia Children’s Hospital Research Institute BRE(B): Behavioural Research Ethics (Board) CDA: Canadian Dental Association CFPC: College of Family Physicians Canada CPS: Canadian Pediatric Society CI: Confidence Interval dmft: decayed, missing, filled teeth ECC: Early Childhood Caries ENT: Ear Nose and Throat OR: Odds Ratio PGYI/II: Post Graduate Year I/II REDCap: Research Electronic Data Capture RBR: Rourke Baby Record UBC: University of British Columbia xii Acknowledgements I would like to express my utmost gratitude to my supervisor Dr. Mario Brondani, for his continuous support and mentorship throughout this project, his dedication and work ethics were remarkable. I would like to show my appreciation to Dr. Quynh Doan whose advice and guidance in this project were invaluable and helped shape this project, and to my committee member Dr. Karen Campbell for her valuable feedback. I also thank Dr. Jolanta Aleksejuniene for her efforts and guidance in the statistical part of the study. I would like to thank my co-residents and the amazing staff at the British Columbia Children’s Hospital Department of Dentistry and departments of Pediatric Dentistry and Orthodontics at the University of British Columbia for their support throughout my training Finally, special thanks to my family, their words of encouragement kept me going. Without them this would have not been possible. xiii Dedication This thesis is dedicated to my loving parents Fahad and Haya, who despite the long distance supported me and provided me with much needed guidance as if they were here with me. To my role model and wise brother Turky, who believed in me when no one did. To my beautiful sisters Bashayer, Ghada, Yara, and Norah for their unconditional love. And lastly to Zeus and Hera, coming home to you made everything easy. 1 Chapter 1: Introduction Early childhood caries (ECC) is the most common childhood disease; it is 5 times more prevalent than asthma and 7 times more frequent than hay fever (Surgeon General, 2000). It is often accompanied by serious comorbidities affecting children’s quality of life, their families, the community and the health care system as a whole. Oral health, defined by the World Health Organization as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects, periodontal disease, tooth decay and tooth loss” (World Health Organization, 2012), is an essential element to the overall health. Integrating oral health into primary care can improve a child’s quality of life tremendously. In turn, it is essential to convey to primary health care professionals the knowledge regarding infant oral health care so they can be an allied profession in identifying ECC. These professionals can also play an important role in reducing the incidence of ECC and preventing its costly surgical treatment. 1.1 Early Childhood Caries Early childhood caries is defined by the Canadian Dental Association (CDA) as “the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a preschool-age child (i.e. 71 months of age or younger)” (Canadian Dental Association, 2010). It is estimated that 57% of Canadian children 6 to 11 years of age have experienced dental decay, with an average of 2.5 teeth affected by decay per child. Although in certain urban areas of Canada the prevalence of ECC in preschool children is 6% to 8%, in some disadvantaged Indigenous communities the prevalence of decay exceeds 90% (Rowan-Legg, 2013). According to the CDA, treatment for ECC under general anesthesia is the 2 most common day surgery under general anesthesia at most pediatric hospitals in Canada, it costs annually more than $21.18 million to the tax payers, and burdens the child’s quality of life (Schroth, Quiñonez, Shwart, & Wagar, 2016). Despite its high prevalence, ECC is highly preventable through dietary changes, oral hygiene, and topical fluoride therapies, for example. Early ECC identification allows for reduction in its burden, arrest of incipient lesions and even prevent the disease progression. 1.2 Use of Fluoride in Caries Prevention The use of fluoride in dentistry has proved to be effective in preventing, remineralizing and arresting decay. Fluoride is widely available in different forms; almost all food and naturally occurring water contain some fluoride. Furthermore, community water fluoridation at a concentration of 0.7 mg/L(milligrams per litre) seems to be optimal for the daily uptake of fluoride (Rabb-Waytowich, 2009) while being one of the 10 greatest public health achievements of the 20th century (Centers for Disease Control and Prevention, 2000). However, as of 2017 only 38.7% of Canadian provinces and territories have fluoridated water; 1.17% of British Columbians have fluoridated water (Public Health Agency of Canada, 2018). A way to supplement (and probably overcome) this low reach of fluoridated water is the periodic professional application of different forms of fluoride in infants and children, particularly those at high risk for ECC. Professionally applied fluoride along with over-the-counter fluoride-containing toothpastes, gels, and rinses can offer significant cariostatic properties that contribute positively in reducing ECC (Lawrence et al., 2008; Weyant et al., 2013). 3 1.3 Access to Oral Health Care and Primary Care The American Academy of Pediatric Dentistry (AAPD) and the CDA recommends that dental assessment of infants should be carried out within 6 months of the eruption of the first tooth, no later than year 1 of age (American Academy of Pediatric Dentistry, 2017; Canadian Dental Association, 2010). However, there has been limited uptake on this recommendation. The Canadian dental care delivery system is complex and costly, and remains mostly privately financed and administered (Rowan-Legg, 2013). Many studies have then advocated for primary care physicians to play a more active role in the prevention and early detection of ECC (Douglass, Douglass, & Silk, 2005; Lewis et al., 2009; Lewis, Grossman, Domoto, & Deyo, 2000; Prakash et al., 2006). Given that oral health is an essential element to the overall health, integrating oral health into pediatric primary care can only improve the overall quality of life of a child while integrating care holistically. By the age of 3, a child is believed to be seen more than 10 times by a family physician than by a pediatrician, and much less so by a dental professional (Hale, 2003; Prakash et al., 2006). Such visits can benefit the oral health of the child, optimize the utilization of fluoride, and help to decrease the incidence of ECC (Weatherspoon, Horowitz, & Kleinman, 2016). As found by Kranz and colleagues, kindergarten children with 4 or more physician-based preventive oral health services during the well-baby visits had lower decayed, missing, filled teeth (dmft) compared to children without these visits, 1.82 and 2.21 respectively (Kranz, Preisser, & Rozier, 2015). In turn, early assessment of the oral health as well as oral health promotion can be achieved during well-baby visits together with general health assessment. There are different well-baby visit resources, one of which is the Rourke baby record (RBR) as shown in Appendix 4 A. This record was developed by Leslie and James Rourke in 1979 and enables family physicians and pediatricians to track the development of infants by charting data collected during well-baby visits and assesses different milestones such as immunizations and diet, and thus provides a comprehensive care to the child (Riverin, Li, Rourke, Leduc, & Rourke, 2015). Although comprehensive, it does not provide adequate dental screening and only lists dental care in the ‘other’ section as part of the ‘education and advice’ domain; oral health status is not included in the ‘physical examination’ domain. The extent to which this ‘other’ section is used and the periodicity in which dental screening in performed by primary care physicians remains unknown. Another assessment tool developed by the American Academy of Pediatrics (AAP) that can be used for the oral health risk assessment is shown in Appendix B. This tool covers all the aspects of a risk assessment that helps guide the health care professional in determining those at high risk and the appropriate decisions thereafter (American Academy of Pediatrics, 2014). A self-management sheet is also available that aids in the process of anticipatory guidance of parents and caregivers while guiding them towards setting self-management goals that can be tracked in terms of oral health care, dental visits, and dietary modifications (Ramos-Gomez & Ng, 2011) (Appendix C). The utilization of interdisciplinary collaboration (by crossing the set boundaries and norms of different health and medical professional practices) is much needed to further enhance children’s oral health and have a positive influence on their quality of life (Nancarrow et al., 2013). Such interprofessional collaboration could include not only pediatric physicians, but also general physicians and community health nurses. In terms of pediatric primary care physicians delivering 5 preventive oral health care regimen, studies have concluded that they are able to apply fluoride varnish and accurately identify children with carious teeth after receiving training in infant oral health care (Pierce, Rozier, & Vann, 2002). Considering the potential role of allied professionals in promoting oral health, integrating an oral health component in the residency training of primary health care professionals’ curriculum is recommended (Hale, 2003; Indira, Dhull, & Nandlal, 2015; Prakash et al., 2006). In fact, Pahel et al. supports the findings of the study done by Pierce et al. in which medical office-based preventive dentistry program for children can effectively reduce dental-related treatment needs (Pahel, Rozier, Stearns, & Quinonez, 2011). Hence, in 2014 Silk and Deutchman developed an educational module to deliver oral health preventive practices to health care professionals that could be carried out in a pediatric primary health care setting (Silk & Deutchman, 2014). This module entails assessing the caries risk of the child, performing oral exams and applying fluoride varnish. In 2018 Nicolae et al. designed an oral health office-based screening tool to help primary care providers identify ECC with images depicting the progress of tooth decay (Appendix D). This tool provides guidance on how to properly lift the lip and check for tooth decay on an easy to understand and quick to apply manner (Nicolae et al., 2018). 1.4 Oral Health Knowledge of Health Care Professionals Studies from the United States (Brickhouse, Unkel, Kancitis, Best, & Davis, 2008; Herndon, Tomar, Lossius, & Catalanotto, 2010; Lewis et al., 2009; Lewis et al., 2000; Long et al., 2012; Long, Quinonez, Rozier, Kranz, & Lee, 2014; Okunseri, Szabo, Jackson, Pajewski, & Garcia, 2009; Pierce et al., 2002; Schulte, Druyan, & Hagen, 1992; Slade, Rozier, Zeldin, & Margolis, 6 2007), Europe (Bottenberg, Van Melckebeke, Louckx, & Vandenplas, 2008; dela Cruz, Rozier, & Slade, 2004; Ismail, Nainar, & Sohn, 2003; Sánchez, Childers, Fox, & Bradley, 1997; Sezer, Paketci, & Bozaykut, 2013), and India (Indira et al., 2015; Nammalwar & Rangeeth, 2012) have examined the knowledge, attitudes, and practices of primary care physicians towards infant oral health. Allied health care professionals are well positioned to provide anticipatory guidance and referral for dental care prior to any progression of disease given that they have the opportunity to see children at an early age (Ryan-Wenger, 2007). In particular, Schulte et al. surveyed 298 pediatricians in the greater Chicago area, and found that 96% of the participants refer children to the dentist once decay has been diagnosed, of those pediatricians, about 65% of them recommended changes to dietary habits (Schulte et al., 1992). In 1997, Sánchez et al. conducted a similar survey targeting pediatricians’ and family physicians’ knowledge and attitudes towards preventive dental care in children. The authors hypothesized that primary care physicians are not well-informed about preventive dental care likely due to the lack of information received during the residency training given that only 68% of the participants thought that children should have their first dental visit by the age of 3 (Sánchez et al., 1997). On a large national study of 1600 pediatricians in the U.S., Lewis et al. found that 90% of participants agreed about their role in identifying dental problem and counseling families on the prevention of caries. Nevertheless, only 9% correctly answered all four knowledge questions regarding ECC (Lewis et al., 2000). In 2009, the same research group (Lewis et al., 2009) did another national survey of pediatricians, which demonstrated that 54% of participants reported examining the teeth of their 0 to 3-year-old patients. Only 4% of the respondents actively applied fluoride varnish. However, the authors reported little change from 7 the previous survey in terms of the number of pediatricians who refer children to the dentist by their first birthday. Similarly, Ismail et al. conducted a survey targeting pediatricians and family physicians involving case-based questions regarding ECC. Almost all the respondents were in agreement that they should screen children for dental caries; about 76% of family physicians reported they screened for ECC (Ismail et al., 2003). In a survey of 118 primary care clinicians investigating their dental screening and referral of young children, dela Cruz and coworkers found that 78% of the participants were likely to refer children who had signs of ECC or were at high risk for future disease to a dental professional (dela Cruz et al., 2004). In a more recent survey of Maryland physicians, results showed that participants still held some uncertainties around dental caries etiology and prevention (Weatherspoon et al., 2016). There have been studies on this topic outside the U.S. as well. In 2008, Bottenberg et al. examined the knowledge of Flemish pediatricians in regards to oral health of children to found that only 7% of pediatricians prescribed fluoride supplements, but that 73% were aware of ECC (Bottenberg et al., 2008). Sezer et al. studied the awareness of Turkish pediatricians towards children’s oral health to find that only 13.9% of the participants referred children younger than one year of age to a dental professional, while 10.3% of the participants prescribed fluoride supplements to their patients (Sezer et al., 2013). In a survey of pediatricians’ knowledge, attitude, and practice towards infant oral healthcare in India, only 48% of the respondents would refer their patients to a pediatric dentist, while 43% of them were aware of the recommended first dental visit by the age of 1, and more than 90% of them examined infants for ECC (Indira et al., 2015). 8 In Canada, similar studies are sparse. More than a decade ago, Prakash et al. conducted a national study on pediatricians’ and family physicians’ knowledge, practices and training towards early childhood caries and infant oral health. They found that 46% of Canadian pediatricians and family physicians were not aware that white spots on tooth surfaces were the first signs of tooth decay. Furthermore, only 1.8% of pediatricians and 0.7% of family physicians answered all knowledge questions correctly and despite being knowledgeable about some aspects of ECC, they were not able to identify ECC or to incorporate oral health promotion in their practices (Prakash et al., 2006). Since 2006, various initiatives have been developed in attempts to include oral health into primary care, and other general health care programs. Douglass et al. developed an infant oral health training program to pediatric and family medicine residents and found that participants’ knowledge and practices regarding prescribing fluoride were modest (Douglass et al., 2005). Similarly, Caspary et al. found that most pediatric residents believed that they should be conducting oral health-risk assessments and screenings but lack the skills to do so; they had limited to no oral health training during their residency (Caspary, Krol, Boulter, Keels, & Romano-Clarke, 2008). In 2013 Golinveax et al. had pediatric nurse practitioner students participating in an interdisciplinary and multifaceted oral health educational intervention; around 83% of the participants were actively incorporating oral health service as a part of their routine child care (Golinveaux et al., 2013). Furthermore, the American Academy of Family Physicians has endorsed a web-based comprehensive oral health curriculum titled “Smiles for Life” that offers free CME credits upon completing the modules. Smiles for Life consists of eight 45-minute modules, one specific for child oral health and another for caries risk assessment, fluoride varnish and counselling (Clark et al., 2010). In fact, the Smiles of Life module on ‘Child Oral Health’ has been adapted exclusively to the Canadian context after 2010, 9 and oral health care education has been endorsed by various health care professions in Canada including family physicians, public health nurses, and pediatricians. In turn, the knowledge, attitudes, and practices of primary care physicians towards infant oral health in Canada needed to be reexamined given the many initiatives that have been developed to bring oral health into primary care since 2006. 1.5 Objectives 1. To evaluate the current content pertaining to infant oral health within the curricula of family medicine residency training in Canada. 2. To assess the attitudes and practices of family medicine residents towards infants’ oral health care. 3. To identify barriers faced by family medicine residents for performing various oral health-related practices. 1.6 Research Questions 1. What is the current infant oral health content within the curricula of family medicine residency training? 2. What is the status of the family medicine residents’ oral health education training? 3. What are the attitudes and practices of family medicine residents towards infants’ oral health care? 4. What are the barriers facing family medicine residents for performing various oral health related-practices? 10 1.7 Hypotheses 1. There is a lack of formal oral-health related education in the family medicine curricula. 2. Family medicine residents are not well-informed on preventive dental care and oral health-related practices due to a lack of oral health-related education during residency training. 3. Preventive dental care for infants is not carried out routinely in a primary care setting. 4. Family medicine residents are not referring infants to dentists routinely. 11 Chapter 2: Materials and Methods 2.1 Research Design and Methods A survey of family medicine residency directors (including directors of rural training centers) and family medicine residents in Canada was conducted using a self-administered questionnaire (please see description ahead, and Appendix E and Error! Reference source not found., respectively). Research Electronic Data Capture - REDCap was used as a method of collecting and managing the data hosted by the British Columbia Children’s Hospital Research Institute (BCCHR). REDCap is a secure web-based application for managing online surveys and databases (Harris et al., 2009). The sample frame was all the 17 Family Medicine residency programs in Canada using a list obtained through the College of Family Physicians of Canada (CFPC) and included the University of Alberta, University of British Columbia, University of Calgary, Dalhousie University, Laval University, McGill University, McMaster University, University of Manitoba, Memorial University, University of Montreal, Northern Ontario School of Medicine, University of Ottawa, Queen’s University, University of Saskatchewan, University of Sherbrooke, University of Toronto, and University of Western Ontario; some of the programs had more than one identified director in cases there was a rural/remote setting location, for example. While the directors were identified through each residency programs’ website, the residents survey was distributed through the department of family medicine at each program. The directors’ survey (Error! Reference source not found.) consisted of 19 multiple choice, open-ended, agreement/ disagreement, and yes/no questions. The residents survey (Appendix E) 12 consisted of 23 multiple choice, open-ended, agreement/ disagreement, and yes/no questions. Both surveys were developed from the existing literature and from informal conversations with pediatricians and public health specialists. The content of the surveys included integration of oral health-related subjects in the curriculum, and the residents’ attitudes and practices towards the infants’ the oral health along with some demographic characteristics of the training programs and the residents themselves. A pilot study was conducted among 5 graduate dental students and 5 pediatrics residents at the University of British Columbia who evaluated the questions of the survey. Upon analysis of the pilot study, appropriate revisions to the survey were made, including adding a question about the number of children seen during rotations, and removing the redundant questions. Prior to data collection, ethics approval was obtained from the University of British Columbia (#H17-00453), as well as the University of Alberta (#Pro00085423). 2.2 Study Procedures 2.2.1 Directors’ Survey REDCap was used to send a standardized e-mail (Appendix G) to all programs directors (including rural sites) from the 17 family medicine programs in Canada to a total of 21 directors including the remote and rural sites. The directors were informed about the nature of the study including the background, rationale, objectives, and the rights associated with their decision to participate or decline as study subjects. The e-mail also contained a unique link generated by REDCap to the online survey questionnaire inviting them to participate in the survey. Upon clicking the link, potential participants received a consent cover letter explaining the nature of 13 the survey and the time required to complete it which was around 10 minutes, along with the questionnaire to complete. Participation was voluntary. REDCap tracked if each participant had responded to the survey or not. Data collection commenced in July 2018; reminder e-mails were sent to subjects who have not yet responded at 2 weeks, 1 month, and 2 months, following the original invitation. Although participation status was tracked using unique links, there was no attempt to identify the participants or to match their responses with the respective program; surveys were coded numerically. Once data entry and validation were completed, the unique responder tracking identification was removed to prevent further linkages. Only de-identified data were analyzed and used for this thesis. No financial incentive for survey completion was offered to the directors of the programs. Data collection was completed by September 2018. 2.2.2 Residents’ Survey From the total possible sample of the 3217 residents enrolled within the college of family physicians in 2018 (College of Family Physicians of Canada), 565 residents were excluded from the two French-speaking programs as the survey was in English only. From the 2652 residents from 15 remaining programs, not all of them received the email with the survey link as at least 7 programs informed that they only distributed the survey to a smaller number of residents; these programs did not offer any reason as to why only a certain number of residents were contacted and the remaining 8 programs did not clarify on whether all their residents received the survey. The sample frame for the residents was not more than 2652 and the sample size calculation was 14 estimated at 388 residents. And unlike the directors’ survey, REDCap did not track if each participant had responded to the survey or not. Similarly to Directors’ survey, a standardized e-mail was sent to each of the 17 family medicine residency program coordinators (Appendix G) via REDCap asking for the participation of their family medicine residents, and informing them of the nature of the study, including the background, rationale, objectives, and their rights associated with their decision to participate or decline as study subjects. The e-mail also contained a unique link to the online survey questionnaire. Upon clicking the link, each participant received a cover letter explaining the nature of the survey and the time required to complete it which was about 10 minutes, along with the questionnaire to complete. Data collection commenced in July 2018, a reminder e-mail was sent to subjects at 2 weeks, 1 month, and 2 months via their program coordinator, following the original invitation. There were no attempts to identify individual participants for any other reasons, and surveys were coded numerically. Participation was voluntary and anonymous. No financial incentive for survey completion was offered to the residents. Data collection was completed by September 2018. 2.3 Data Collection and analysis De-identified demographic information including age, gender and city of residence were asked for characterization of the participants only. The variables defined and explored in the survey instrument are outlined as follows: The variables of interest for the directors’ survey were related to the total hours of didactic oral health training the residents receive during their family medicine training, the methods of 15 evaluation of the residents’ oral health knowledge, and the perceived barriers towards teaching oral health related topics, the oral health-related topics included in the family medicine curriculum (oral health screening, dental disease prevention and early intervention, ECC, oral and general health interaction, pregnancy and oral health, and fluoride varnish) and the oral health-related topics taught in during well-baby visits (oral and teeth assessments, dietary habits, parental counselling, and dental referrals). The independent variables for the residents’ survey were related to age, gender, the postgraduate year they were in, the frequency of children seen per week, the frequency of which they saw children with tooth decay, the quality of the training received, their perceived barriers towards performing oral health-related practices, availability of government-sponsored dental coverage, the availability of shared primary care services with pediatricians, and their attitudes towards (the use of fluoride toothpaste, importance of primary dentition, adequacy of training on oral health, and importance of physicians’ role on promoting oral health). The outcome variables were the various oral health-related practices (visually examining the child’s teeth, counselling parents on teething and dental care, assessing the child’s risk for tooth decay, advising the parents or caregivers on teeth cleaning methods, discuss the use of fluoridated toothpastes, and referring to a dentist). In the bivariate analyses, the importance of the physicians’ role was dichotomized as not/less important (strongly disagree/ neutral) and important (agree, strongly agree). Similarly, for the multivariate analyses, the responses ‘good and excellent’ and ‘disagreed, strongly disagreed and neutral’ were collapsed together due to low number of responses. Data collected via RECap were generated using Microsoft Excel (Excel 2015, Microsoft 16 Corporation, Redmond, WA.) spreadsheet. Descriptive analysis was computed, and bivariate analyses were performed to assess the association between family medicine residents’ attitudes and oral health-related practices and factors such as their postgraduate year, area of residency, children seen per month, dental caries observed during well-baby visits, quality of training, perceived barriers to carrying out preventive dental practices. Bivariate analyses (Chi-Square test, and Fischer’s Exact), and logistic regression tests were performed for categorical variables. The statistical analysis was performed using SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Macintosh, Version 22.0. Armonk, NY: IBM Corp.) and tests were conducted at a confidence interval (CI) of 95%, and a significance level of 0.05. 17 Chapter 3: Results Out of the 21 directors from the 17 residency programs (please see Study Procedures above) that received the survey invitation, a total of 11 completed the survey (52% of response rate). Although the number of residents who actually received the survey is unknown, a total of 155 responses were received (less than <1% of response rate given the original enrolment number of 2652). 3.1 Descriptive Statistics 3.1.1 Family Medicine Oral Health Curriculum and training Figure 1 demonstrates whether specific oral health-related topics were included in the family medicine curriculum. From the directors’ responses, ten (90%) indicated that clinical oral health screening was not incorporated in the curriculum, while 72% (n=8) of the directors indicated that their curriculum did not include dental disease prevention, early intervention, and ECC. Similarly, the interaction between oral health and general health as well as pregnancy and oral health was not included in 72% of the programs (n=8). All directors indicated that fluoride varnish was discussed in the curriculum. More than half of the directors (n=6) said that their residents received approximately 1-3 hours of didactic information on oral health-related topics during their entire training. Family medicine residency directors were also asked about specific oral health-related topics taught during the residents training (Figure 2). Nearly two thirds (63%, n=7) of the directors indicated that the visual examination of the oral cavity and the child’s teeth and the child’s risk assessment of tooth decay were taught didactically. Over half the directors (54%, n=6) indicated 18 that they only didactically teach their residents on discussing nocturnal bottle feeding, and fluoride toothpaste with the parents/caregivers as well as referring children to a local dentist. About 63% of them (n=7) indicated that their residents received both didactic and clinical information on the application of topical fluoride products, while 45% of them (n=5) also reported teaching their residents both didactically and clinically on prescribing fluoride supplements. The most common barriers reported by family medicine directors towards teaching infant oral health-related practices to their residents were competing priorities, knowledge and family physician’s scope of practice (63%, n=7), and time (45%, n=5). Furthermore, the majority of directors (81%, n= 9) indicated that they have no method of evaluation of their resident’s oral health knowledge. Figure 1 – Oral health-related topics included in family medicine curriculum 27.727.745.427.727.70 10 20 30 40 50 60 70 80 90 100CLINICAL ORAL HEALTH SCREENINGDENTAL DISEASE PREVENTION AND EARLY INTERVENTIONEARLY CHILDHOOD CARIESDIETARY PRACTICESTHE INTERACTION BETWEEN ORAL AND GENERAL HEALTHPREGNANCY AND ORAL HEALTHFLUORIDE VARNISHOral Health-Related Topics Included in Curriculum 19 Figure 2 – Oral health-related practices formally taught in family medicine curriculum 999963.663.654.563.663.654.527.218.154.527.718.845.536.327.227.218.1918.118.89945.463.618.1ASSESSMENT THE ORAL CAVITY OF THE CHILDDENTAL ASSESSMENTINQUIRE WHETHER A CHILD IS TAKING A BOTTLE TO BEDORAL HEALTH CARE COUNSELLING CARIES RISK ASSESSMENTDISCUSS THE USE OF FLUORIDEPRESCRIBE FLUORIDE SUPPLEMENTSAPPLY TOPICAL FLUORIDEDENTAL REFERRALOral health-related practices taught in family medicine residencies Not taugh Only didactically Only clinically Both didactically and clinically 20 3.1.2 Residents’ Demographics and Practice Characteristics Demographic information and practice characteristics are presented in Table 1. Female residents comprised the majority of the respondents to the survey (83%, n=128). Seventy percent (n=108) of respondents were based in the eastern provinces; with 50% (n=78) of the total responses coming from residents training in Ontario. About 52% (n=80) were in their second year of training while 46% of them (n=71) were in their first year of training; mean age of the participants was 29 years. The vast majority of the residents (90%, n=140) reported that they utilized the Rourke Baby Record. The majority of the residents (75%, n=117) seldom saw children younger than 3 years of age, while 76% of them (n=118) had not seen a child with tooth decay. 21 Table 1 – Characteristics of the residents Demographics and Practice Information N (%) Total: 155 Gender Male Female 27 (17.0) 128 (83.0) Province of training Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan 17 (11.0) 6 (4.0) 8 (5.0) 5 (3.0) 3 (2.0) 11 (7.0) 78 (50.0) 1 (1.0) 11 (7.0) 15 (10.0) Year of Residency PGY1 PGY2 PGY3 71 (46.0) 80 (52.0) 4 (3.0) Utilization of Rourke Baby Record Yes No Availability of provincial dental coverage Yes No 140 (90.3) 15 (10.0) 24 (15.0) 131 (85.0) Frequency of weekly pediatric assessment (age 0-3years) None Seldom (1-5 children/ week) Frequently (> 5 children/ week) 3 (2.0) 117 (75.0) 35 (23.0) Frequency of pediatric tooth decay identification/week None Seldom (1-5 children/ week) Frequently (> 5 children/ week) 118 (76.0) 35 (23.0) 2 (1.0) 22 3.1.3 Oral Health-Related Practices of Family Medicine Residents As shown in Table 2, residents were asked about the frequency to which they performed certain oral health-related practices for children aged 1-3 years-old. A total of 96 (62%) of the respondents seldom performed a visual examination of the teeth of the children, while nearly half (48%, n=75) of the residents frequently counseled parents or caregivers regarding teething and dental care; not more than 46% of the respondents (n=72) reported advising the parents or caregivers on teeth cleaning methods. Over half the respondents (53%, n=82) assessed the child’s risk for developing tooth decay. When asked about discussing the use of fluoride toothpaste with the parents or caregivers, and referring children aged 1-3 years old to a local dentist, the residents reported that they seldom did these activities (40%, n=62; 43%, n=67, respectively). Around 52% of the residents (n=81) indicated that if dental caries was observed, they would refer the child to the dentist, but only 11% (n=17) would make a formal referral. Lastly, half the respondents (n=79) reported recommending bottle weaning between 12 and 24 months of age. 23 Table 2 – Family medicine residents’ oral health-related practices Oral Health-Related Practices of Residents N (%) Total: 155 Dental assessment of the child’s teeth Never Seldom Frequently Always 18 (11.6) 96 (61.8) 29 (18.7) 12 (7.7) Counsel parents/ caregivers regarding teething and dental care Never Seldom Frequently Always 9 (6.0) 48 (31.0) 75 (48.0) 23 (15.0) Caries risk assessment of the child’s teeth Never Seldom Frequently Always 37 (24.0) 82 (53.0) 28 (18.0) 8 (5.0) Advise parents/ caregivers on teeth cleaning methods Never Seldom Frequently Always 39 (25.0) 72 (46.0) 36 (23.0) 8 (5.0) Discuss the use of fluoride toothpaste with parents and/or caregivers Never Seldom Frequently Always 58 (37.0) 62 (40.0) 30 (19.0) 5 (3.0) Dental referral Never Seldom Frequently Always 48 (31.0) 67 (43.0) 33 (21.0) 7 (5.0) 24 3.1.4 Resident’s Attitudes Towards Oral Health-Related Topics Table 3 shows the attitudes of family medicine residents towards oral health-related statements. One third of the residents (33%, n=51) agreed that fluoride toothpaste should be used for children under the age of 3, while 49% (n=76) strongly agreed that primary teeth were important even if they exfoliate. When asked if physicians have an important role in prompting oral health among infants and toddlers, 61% (n=94) of the residents agreed. 25 Table 3 – Family medicine residents’ attitudes towards oral health-related statements Oral Health-Related Statements N (%) Total: 155 Fluoride toothpaste should be used for children under the age of 3 Strongly Disagree Disagree Neither agree or disagree Agree Strongly Agree 5 (3.0) 36 (23.0) 48 (31.0) 51 (33.0) 15 (10.0) Baby teeth are important even though they fall out Strongly Disagree Disagree Neither agree or disagree Agree Strongly Agree 0 (0.0) 0 (0.0) 3 (2.0) 76 (49.0) 76 (49.0) I feel my training is adequate for me to identify dental caries in children Strongly Disagree Disagree Neither agree or disagree Agree Strongly Agree 32 (21.0) 82 (53.0) 27 (17.0) 11 (7.0) 3 (2.0) Physicians have an important role in promoting oral health among infants and toddlers Strongly Disagree Disagree Neither agree or disagree Agree Strongly Agree 0 (0.0) 1 (1.0) 13 (8.0) 94 (61.0) 47 (30.) 26 3.1.5 Resident’s Oral Health-Related Training and Education Over half the respondents (53%, n=82) reported that they did not feel their training was adequate to identify dental caries in children (Table 3). More than 40% (n=63) of the family medicine residents reported that the quality of their training in oral health-related topics was poor and 39% (n=60) stated that they did not receive any oral health-related training (Figure 3). Furthermore, when asked about potential barriers to perform oral health-related practices, the majority (72%, n=112) of the respondents reported a lack of knowledge or training. By using free-texted narrative, respondents also expanded on the barriers to perform oral health-related practices by mentioning “less than one week was spent on combined oral health and ear nose and throat (ENT) in medical school, with no clinical correlation”, “the amount of training we have makes it difficult to feel confident in this area”, and “we had one lecture on teeth (it wasn't even focused on oral hygiene - but more on anatomy and location of teeth)”. Additionally, the vast majority (95%, n=148) of the residents reported that they would like to have more information/resources on identifying dental conditions and disease in infants. They further indicated that they specifically would like to know more about ECC (90%, n=140), and oral home care (86%, n=133) (Figure 4). 27 Figure 3 – Family medicine residents’ quality of training in oral health-related topics Figure 4 – Oral health-related topics the family medicine residents would like to know more about 3941155 1Residents' reported training quality in oral health-related topicsDid not receive any oral health-related subjects during residency program.PoorFairGood9086725373740 10 20 30 40 50 60 70 80 90 100IDENTIFICATION OF EARLY SIGNS OF ECCHOME PREVENTION OF DENTAL CARIES AMONG …DENTAL CARIES MANAGEMENT IN CHILDRENEFFECTS OF WATER FLUORIDATIONTOPICAL FLUORIDES AND FLUORIDE SUPPLEMENTSTOOTH ERUPTIONOral Health-Related topics the resident's would like to know more about 28 3.2 Inferential Statistics Bivariate analysis was performed. In the question about resident’s attitude towards the importance of physician’s role in promoting oral health to infants and toddlers, Likert scale responses (strongly disagree to strongly agree) were dichotomized to important and not/ less important (Table 4). Significant association was found between residents who felt that physicians had an important role in promoting oral health to infants and toddlers, and who counseled parents or caregivers regarding teething and dental care (p=0.006), and who discussed fluoride toothpaste use with parents or caregivers (p=0.023). Table 5 shows that a significant association was found between family medicine residents’ attitudes towards the importance of primary dentition and various oral health-related practices. There was a significant association between residents who felt that primary dentition was important and performing an assessment of the child’s teeth (p= <0.001), counselling parents (p=0.008), assessing the child’s risk for developing caries (p=0.001), advising the parents on teeth cleaning methods (p=0.003), and discussing the use of fluoridated toothpastes (p=0.025). There was no significant association between the residents’ attitudes and referrals to a dentist. When comparing the residents’ reported frequency of seeing children between 1 and 3 years of age and their oral health-related practices, no significant association was found (data not shown). Nonetheless, as shown in Table 6, there was a significant association between residents who reported observing dental caries and performing an assessment of the child’s teeth (p=0.003), as well as referring children to a dentist (p=0.047). The reported year of training (PGY1, PGY2) indicated that residents in their first year were less likely to visually examine the child’s teeth 29 (p=0.035) and discuss the use of fluoridated toothpastes with the parents (p=0.050) than those in year 2 of their training (Table 7). A comparison between residents from the Canadian east and west provinces, and their attitudes towards the importance of physicians’ role in promoting oral health among infants and toddlers, the frequency of seeing children between 1 and 3 years of age, and the reported frequency of observed dental caries among children 1-3 years of age reveled no significant association. Similarly, no significant association was found between residents from the Canadian east and west provinces and their oral health-related practices (data not shown). There were also no significant differences in any of the practice patterns between the residents perceiving different barriers for their oral health-related practices (Table 8). Table 9 presents the analysis of the explanatory variables associated with the residents performing dental assessments on children. In regards to the importance of the physicians’ role in promoting oral health to infants, the scores of good and excellent were collapsed together as there was only one respondent who indicated their training quality was excellent. This logistic regression model indicates that the residents who reported their training quality as poor were significantly less likely to perform a dental assessment of the children’s teeth (OR=0.38; CI=0.15, 0.99). Furthermore, residents who strongly agreed to the importance of their role in promoting oral health to infants were 6 times more likely to perform a dental assessment (OR=6.09; CI=1.12, 33.0). Residents who were training in provinces where some level of dental coverage was provided by the provincial government, and where pediatricians were providing 30 primary care services for children were more likely to perform a dental assessment (OR=1.23; CI=0.39, 3.90, and OR=1.41; CI=0.60, 3.31 respectively). Table 10 shows the findings of the testing of the explanatory variables associated with the residents providing oral health counselling to parents or caregivers. Residents who strongly agreed to the importance of promoting oral health to infants were significantly 5 times more likely to provide oral health counselling (OR=4.91; CI=1.21, 19.8). 31 Table 4 – Association between residents with different attitudes about their role in promoting oral health and performing oral health-related practices PRACTICE PATTERNS PHYSICIAN’S ROLE Significance# Not/Less important Important N (% of total) N (% of total) Dental assessment of the child’s teeth Never/seldom 12 (85.7) 102 (72.3) 0.279 Frequently/always 2 (14.3) 39 (27.7) Parental counselling Never/seldom 10 (71.4) 47 (33.3) 0.006* Frequently/always 4 (28.6) 94 (66.7) Caries risk assessment Never/seldom 12 (85.7) 107 (75.9) 0.406 Frequently/always 2 (14.3) 34 (24.1) Advise parents about tooth cleaning Never/seldom 13 (92.9) 98 (69.5) 0.065 Frequently/always 1 (7.1) 43 (30.5) Discuss the use of fluoride Never/seldom 14 (100.0) 106 (75.2) 0.023* Frequently/always 0 (0.0) 35 (24.8) Dental referral Never/seldom 13 (92.9) 102 (72.3) 0.094 Frequently/always 1 (7.1) 39 (27.7) # Chi square test or Fischer’s Exact test * p <0.005 32 Table 5 – Association between physicians with different attitudes about the importance of primary dentition and oral health-related practices PRACTICE PATTERNS IMPORTNACE OF PRIMARY DENTITION Significance# Not/Less important Very important N (% of total) N (% of total) Dental assessment of the child’s teeth Never/seldom 69 (87.3) 45 (59.2) <0.001* Frequently/always 10 (12.7) 31 (40.8) Parental counselling Never/seldom 37 (46.8) 20 (26.3) 0.008* Frequently/always 42 (53.2) 56 (73.7) Caries risk assessment Never/seldom 69 (87.3) 50 (65.8) 0.001* Frequently/always 10 (12.7) 27 (34.2) Advise parents about tooth cleaning Never/seldom 65 (82.3) 46 (60.5) 0.003* Frequently/always 14 (17.7) 30 (39.5) Discuss the use of fluoride Never/seldom 67 (84.8) 53 (69.7) 0.025* Frequently/always 12 (15.2) 23 (30.3) Dental referral Never/seldom 61 (77.2) 54 (71.1) 0.381 Frequently/always 18 (22.8) 22 (28.9) # Chi square test * p <0.005 33 Table 6 – Association between physicians who observed and did not observe caries and oral health-related practices PRACTICE PATTERNS PHYSICIAN OBSERVED DENTAL DECAY Significance# NO YES N (% of total) N (% of total) Dental assessment of the child’s teeth Never/seldom 94 (79.7) 20 (54.1) 0.003* Frequently/always 24 (20.3) 17 (45.9) Parental counselling Never/seldom 45 (38.1) 12 (32.4) 0.336 Frequently/always 73 (61.9) 25 (67.6) Caries risk assessment Never/seldom 93 (78.8) 26 (70.3) 0.196 Frequently/always 25 (21.2) 11 (29.7) Advise parents about tooth cleaning Never/seldom 83 (70.3) 28 (75.7) 0.343 Frequently/always 35 (29.7) 9 (24.3) Discuss the use of fluoride Never/seldom 93 (78.8) 27 (73.0) 0.298 Frequently/always 25 (21.2) 10 (27.0) Dental referral Never/seldom 92 (78.0) 23 (62.2) 0.047* Frequently/always 26 (22.0) 14 (37.8) # Chi square test *p<0.005 34 Table 7 – Association between physicians in different years of training and their oral health-related practices PRACTICE PATTERNS PHYSICIAN Training Year Significance# PGY1 PGY2 N (% of total) N (% of total) Dental assessment of the child’s teeth Never/seldom 47 (66.2) 65 (81.3) 0.035* Frequently/always 24 (33.8) 15 (18.8) Parental counselling Never/seldom 28 (39.4) 28 (35.0) 0.573 Frequently/always 43 (60.6) 52 (65.0) Caries risk assessment Never/seldom 55 (77.5) 61 (76.3) 0.860 Frequently/always 16 (22.5) 19 (23.8) Advise parents about tooth cleaning Never/seldom 54 (76.1) 54 (67.5) 0.245 Frequently/always 17 (23.9) 26 (32.5) Discuss the use of fluoride Never/seldom 60 (84.5) 57 (71.3) 0.050* Frequently/always 11 (15.5) 23 (28.7) Dental referral Never/seldom 54 (76.1) 58 (72.5) 0.681 Frequently/always 17 (23.9) 22 (27.5) # Chi square test *p<0.005 35 Table 8 – Association between residents’ perceived barriers and their oral health-related practices Practice patterns Physicians: Perceived barriers Significance# Time Training Other^ N (% of total) N (% of total) N (% of total) Dental assessment of the child’s teeth Never/seldom 15 (83.3) 79 (70.5) 20 (80.0) 0.378 Frequently/always 3 (16.7) 33 (29.5) 5 (20.0) Parental counselling Never/seldom 8 (44.4) 43 (38.4) 6 (24.0) 0.311 Frequently/always 10 (55.6) 69 (61.6) 19 (76.0) Caries risk assessment Never/seldom 14 (77.8) 83 (74.1) 22 (88.0) 0.329 Frequently/always 4 (22.2) 29 (25.9) 3 (12.0) Advise parents about tooth cleaning Never/seldom 15 (83.3) 78 (69.6) 18 (72.0) 0.489 Frequently/always 3 (16.7) 34 (30.4) 7 (28.0) Discuss the use of fluoride Never/seldom 16 (88.9) 88 (78.6) 16 (64.0) 0.134 Frequently/always 2 (11.1) 24 (21.4) 9 (36.0) Dental referral Never/seldom 11 (61.1) 82 (73.2) 22 (88.0) 0.125 Frequently/always 7 (38.9) 30 (26.8) 3 (12.0) ^ Competing priorities, access to care, family’s financial ability # Chi square test 36 Table 9 – Multivariate logistic regression model of variables associated with dental assessment Adjusted OR [95% CI] Dental Assessment Training quality No training Poor Fair Good/ Excellent Importance of physicians’ role in oral health promotion Disagree/ Neutral Agree Strongly agree Time as a perceived barrier to oral health-related practices Availability of provincial dental coverage Shared primary care services with pediatricians Ref 0.38 (0.15, 0.99) * 0.81 (0.25, 2.64) 9.14 (0.97, 85.6) Ref 1.80 (0.34, 9.52) 6.09 (1.12, 33.0) * 1.40 (0.48, 4.10) 1.23 (0.39, 3.90) 1.41 (0.60, 3.31) OR: Odds ratio CI: Confidence interval *p<0.005 37 Table 10– Multivariate logistic regression model of variables associated with oral health counselling Adjusted OR [95% CI] Dental Assessment Training Quality No training Poor Fair Good/ Excellent Importance of physicians’ role in oral health promotion Disagree/ Neutral Agree Strongly agree Time as a perceived barrier to oral health-related practices Availability of provincial dental coverage Shared primary care services with pediatricians Ref 1.76 (0.78, 3.98) 1.54 (0.53, 4.44) 4.76 (0.51, 44.1) Ref 3.21 (0.86, 12.0) 4.91 (1.21, 19.8) * 0.53 (0.21, 1.36) 0.67 (2.58, 1.75) 1.69 (0.83, 3.44) OR: Odds ratio CI: Confidence interval *p<0.005 38 Chapter 4: Discussion, future directions and conclusions This study sought to 1) evaluate the current content pertaining to infant oral health within the family medicine residency programs in Canada; 2) assess the attitudes, and practices of family medicine residents towards infants’ oral health care, and 3) identify barriers faced by family medicine residents for performing various oral health-related practices. The results of this study indicated that there seemed to still exist a lack of oral health education within the family medicine residents’ training in Canada as it was in 2006, which is in concurrence with the existing literature. The majority of the directors stated a lack of inclusion of clinical oral health screening, dental disease prevention and intervention, ECC, interaction between oral and general health, pregnancy and oral health and fluoride varnish in the residents’ curricula. Half of the respondents stated that their residents received approximately 1-3 hours of didactic training on oral health education during their entire training, and included didactic sessions on how to visually examine children’s teeth, how to assess the child’s risk for development of dental caries, the effects of nocturnal bottle feeding, and the use of fluoridated toothpastes. A previous study reported that oral health education in a medical setting need to be designed in an efficient way, as didactic teaching alone does not suffice to ensure efficacy of the oral health training (dela Cruz et al., 2004). Most of the directors reported competing priorities, lack of knowledge, and lack of time as the perceived barriers to teaching these oral health-related topics to their residents. A recent study by Silk et al. reported similar findings as only half the programs reported having 1-3 hours of oral health component to cover the use of fluoride, oral health prevention, and oral screening (Silk, 39 Savageau, Sullivan, Sawosik, & Wang, 2018). Similarly, Prakash et al. investigated practicing Canadian family physicians in 2006, and found that one third of them reported 1-3 hours of oral health training during residency and that the vast majority had either no oral health training or felt that it was poor (Prakash et al., 2006); this can be an indication that in the past 12 years there has been no changes to the oral health training in family medicine residency programs in Canada. The vast majority of the directors reported no methods of evaluation of their residents’ oral health knowledge. The residents’ responses can be reflective of the aforementioned findings from the directors, as over half the residents reported a feeling of inadequacy towards their training in identifying dental caries. Furthermore, the findings reported herein were supported by the perceived need for more information/resources in dental diseases (95%, n=148), with the vast majority identifying ECC and oral home care as two topics they would like to know more about as also found in 2006 (Prakash et al., 2006). The lack of oral health training makes it difficult for family medicine residents and physicians to help out in curbing the impact of untreated ECC. The various competing priorities, and lack of faculty expertise in oral health makes it challenging to have a positive oral health involvement in the residents’ training. Although 90% of our respondents use the RBR, many reported the lack of resources or guidelines as perceived barriers to the ability to, and comfort in, performing various oral health-related practices. This can be explained by the fact that although the RBR is endorsed by both the CFPC and the CPS and it is a component of their certification examination in family medicine, the lack of utilization of the dental part might be related to the inadequate oral health training during residency. 40 This study highlighted differences on the family medicine resident’s perceived attitudes towards oral health given that almost 40% of the respondents agreed with the importance of fluoridated toothpastes in children younger than 3 years, while the other 60% did not agree. Such discrepancy might be explained by conflicting resources currently available. For instance, the CPS in its ‘Caring for Kids’ website recommends the use of fluoridated toothpastes only after 3 years of age (Canadian Pediatric Association, July 2018), while the CDA recommends its use in children younger than 3 years based on the caries risk (Canadian Dental Association, 2012). The findings also showed that the residents who felt that they hold an important role in promoting oral health amongst infants and toddlers were more likely to counsel parents on teething and dental care, to discuss the use of fluoride, and to recognize the importance of primary dentition. These findings were in concurrence with previous studies in the literature (Caspary et al., 2008; Prakash et al., 2006). Although it is reassuring that the vast majority of family medicine residents’ attitudes were positive towards various oral health-related topics, their lack of training and knowledge might be a hindering factor in fully integrating oral health prevention and promotion into their practices. The majority of respondents did not perform oral health-related practices during well-baby visits including assessing the child’s teeth and caries risk, and referring to dental professionals. The residents also reported that they rarely or never saw children 3 years or younger. This can be explained by the fact that family medicine residents might have different clinical rotations throughout their residency and depending on their year of training, they might not see children at all. Furthermore, depending on the province of which the residents are training, pediatricians 41 might not be serving as specialists and thus, might be seeing more children than family physicians (Canadian Pediatric Association, July 2018). Another finding revealed that over two thirds of the residents reported never observing dental caries on children 0-3 years of age, which can be explained by the fact that the majority of the respondents did not see children and when they saw, they might not have lifted the lip and know what to look for due to lack of knowledge and training. However, residents also indicated that if dental caries was observed, they most would have advised the parents/caregivers to take the child to the dentist, although only a few would actually make a formal referral to a dental professional. Despite the results from this study, family physicians are a valuable position to accurately assess and refer children with ECC (Pierce et al., 2002), and in also providing preventive dental services (Slade et al., 2007). Surveys remain an important health research method to provide information on attitudes, knowledge, as well as evaluating policies and curricula (Burns et al., 2008; Wiebe, Kaczorowski, & MacKay, 2012). Yet there were several limitations to this study. The response rate was low (n=155) given that it was difficult to access all family medicine residents across Canada as the CFPC does not endorse third-party or external project surveys to its members. Also, the survey did not have a French version which limited the accessibility to French speaking universities and residents. Moreover, there was no accurate measure in place to guarantee that all the enrolled residents in the family medicine programs in Canada received the survey, especially in those family medicine residency programs with multiple sites run by different administrators. In terms of the limitations with the survey itself, residents might have completed the survey based on 42 what they believed the investigators would like to know rather than what they believed was right to answer, which limits the generalizability of the study. The survey was based on self-reported answers, therefore this might not be an accurate representation of the actual training and practices of the residents. For the directors’ survey, the 11 responses also limit generalizability to all residency programs in Canada or elsewhere, especially when considering that there were different sites for each program and each training site might have a director that might not be aware of oral health components of the full curriculum. FUTURE DIRECTIONS Future studies in collaboration with the CFPC are recommended to further understand the gaps in oral health training and education in family medicine residencies, and investigate whether web-based oral health curriculums such as Smiles for life is utilized by family medicine programs in Canada. Another area that needs to be investigated is the perspective of the health care users (i.e. parents and caregivers), as their insight on their beliefs on oral hygiene and fluoride use would provide great value in understanding the prevalence of early childhood caries. Furthermore, it would be of great interest to explore the dental professionals and their attitudes, beliefs, and practices on pediatric and infants’ oral health care, and their actual level of comfort in examining and providing preventive health services to infants and the pediatric population, this in turn will help provide an understanding of the actual root of the problem and in turn will be beneficial in end goal of prevention of early childhood caries. 43 CONCLUSIONS Early childhood caries remains the most common childhood disease, it is often accompanied by serious comorbidities affecting children’s quality of life, and is the main reason for hospitalization under general anesthesia for children under 3-years of age. Therefore, it is essential to convey to primary health care professionals the knowledge regarding infant oral health care so they can be an allied profession in identifying ECC. However, most of the Family Physicians training programs in Canada seemed to not include enough infant oral health screening in their curriculum. While the majority of family medicine residents felt that physicians have an important role in promoting oral health amongst children (i.e. assessment of the child’s teeth, referring to dentists), the reported lack of knowledge and training is hindering them from performing various oral health-related practices. Efforts should be made to increase interprofessional collaboration between dentistry and family medicine curricula; this in turn will help reduce the incidence and severity of ECC. Allied health care professionals remain well positioned to provide anticipatory guidance and referral for dental care prior to any progression of disease given the way the Canadian public health care system in structured with oral health care remaining privately financially and administered. 44 Bibliography AAPD. (2011). 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Why are response rates in clinician surveys declining? Canadian family physician Médecin de famille canadien, 58(4), e225-e228. World Health Organization. (2012). Oral Health Fact sheet N°318. Retrieved from http://www.who.int/mediacentre/factsheets/fs318/en/ 48 Appendices Appendix A – Rourke Baby Record 49 50 51 52 53 54 55 56 Appendix B – AAP Oral Health Risk Assessment Tool 57 58 59 Appendix C – AAP Oral Health Self Management Goals 60 Appendix D – Pediatric Dental Health Screening Guide 61 62 63 Appendix E – Directors’ Survey 64 65 Appendix F – Residents’ Survey 66 67 68 Appendix G – Email Script
Thesis/Dissertation
eng
Craniofacial Science
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Family medicine residents’ oral health-related training, attitudes, and practices towards infant oral health
Text