The data suggest that preschoolers with early. Introducing Infant Oral Health into Dental Curricula: A Clinical Intervention. Evidence-Based Dentistry

Transcription

1 Evidence-Based Dentistry Introducing Infant Oral Health into Dental Curricula: A Clinical Intervention Joshua E. Fein, D.D.S.; Rocio B. Quinonez, D.M.D., M.S., M.P.H.; Ceib Phillips, Ph.D., M.P.H. Abstract: Although pediatric dentists are trained to address the oral health needs of young children, few general practitioners receive this training in dental school. The purpose of this study was to evaluate change in dental students knowledge, confidence, opinions, and behaviors following a curricular intervention in infant and toddler oral health. Using a pre- and post- study design, forty-five intervention and forty-one control group students participated in the study. The intervention consisted of a three-hour seminar, followed by three or four clinical sessions. Descriptive statistics and analysis of covariance were used to compare the average scores of the two groups after adjusting for pre-construct scores. The response rate was 84 percent. The mean scores of the control and intervention groups did not differ significantly for any of the constructs at baseline (p>.14). Bivariate analysis showed the average post-scores differed significantly (p<.01) in the control and intervention groups for all constructs after adjusting for pre-scores. Similar findings occurred in the regression modeling, with previous experience caring for young children, ability to speak Spanish, and gender influencing the outcomes. Eighty-eight percent of the students enrolled in the intervention stated they were more likely to treat children in this age group following this clinical experience. Dr. Fein graduated with distinction in 2009 from the School of Dentistry, University of North Carolina at Chapel Hill and is now a graduate student in endodontics at the University of Maryland; Dr. Quinonez is Clinical Assistant Professor, Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill; and Dr. Phillips is Professor, Department of Orthodontics, School of Dentistry, University of North Carolina at Chapel Hill. Direct correspondence and requests for reprints to Dr. Rocio B. Quinonez, Department of Pediatric Dentistry, CB#7450, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC ; quinoner@dentistry.unc.edu. Keywords: infant oral health, dental education, clinical intervention Submitted for publication 6/16/09; accepted 7/23/09 The data suggest that preschoolers with early preventive dental visits are more likely to use subsequent preventive services and experience lower treatment costs. 1 This finding underscores the importance of having a dental workforce large enough for children to establish a dental home by age one. However, a lack of access to dental services exists among young children in the United States, with approximately 10 percent under the age of five reported to have had preventive dental services. 2 Exacerbating this problem is the steep rise in dental caries among children ages two to five and the limited workforce to address their oral health needs. 3-5 Further, national data indicate that few general dentists treat children younger than four years of age, with only 7 percent reporting care for patients with Medicaid coverage very often or often. 6 Dental education provides an opportunity to help improve the workforce problem and close the gap in delivery of preventive oral health services to young children. To this end, academic institutions are examining models to best educate the dental workforce to address the oral health needs of the youngest and most underserved populations. However, research on educational interventions related to infant and toddler oral health care is limited. Seale and Casamassimo reported that dentists who had performed infant oral health examinations during dental school were significantly more likely to provide oral examinations to children less than three years of age in their current practice. 6 Although a promising finding, this study was limited by its retrospective design evaluating providers previous dental educational experiences and the lack of a control group. In another retrospective study, by Cotton et al., 7 clinical exposures to infants and toddlers in dental school were strongly associated with a positive view of caring for preschool-aged, Medicaid-eligible children by general practitioners. Further, McWhorter et al. reported that while most schools provide their students with exposure to the concept of infant oral examinations, only one in four included October 2009 Journal of Dental Education 1171

2 hands-on experience with related procedures. In addition, dental schools in that study reported that, on average, little curriculum time is dedicated to infant and toddler oral health: a mean and median of two hours twenty minutes and one hour forty-five minutes in their total curriculum, respectively. 8 These data underscore the limited exposure to early childhood care education during dental school. To address the current gaps in dental education and to promote the involvement of dental providers in the care of infants and toddlers, in 2005 the Department of Pediatric Dentistry at the University of North Carolina at Chapel Hill developed the Baby Oral Health Program (bohp). bohp provides senior students with didactic and clinic experiences that enable them to deliver preventive oral health services to young children. It was unclear, however, how this program influenced a number of student constructs, including knowledge, confidence, opinion, and subsequent practice behaviors. The purpose of our study was to prospectively evaluate the changes in these constructs for senior students who are bohptrained compared with those who did not complete the rotation. This information can help improve the current bohp rotation and provide evidence for a best practice model to educate dental students in this arena before they enter practice. Methods The subjects in this study were fourth-year dental students who volunteered to participate in a one-semester bohp rotation based on their progress and/or desire to participate. The study enrolled students over a sixteen-month period (fall of 2007 and spring, summer, and fall of 2008), with approximately fourteen students participating each semester. An equal number of randomly selected nonparticipating senior dental students were included as the control group (Figure 1). All study activities were approved by the Biomedical Institutional Review Board at the University of North Carolina at Chapel Hill, and consents were obtained for all student participants. The bohp intervention consisted of a threehour seminar given by a faculty member from the Department of Pediatric Dentistry, who also serves as the bohp director. The seminar focused on issues related to infant and toddler oral health. This was followed by three or four three-hour clinic sessions with direct patient interaction that consisted of delivering preventive oral health services to children up to age three. The clinical sessions were offered at the dental school or a local community health center, both targeting low-income minority children. The school-based children were a Migrant Early Head Fourth-Year Dental Students at UNC (n=86) n=45 preparticipation n=41 preparticipation Intervention No intervention n=45 postparticipation n=41 postparticipation Figure 1. Study design assessing the influence of the Baby Oral Health Program (bohp) 1172 Journal of Dental Education Volume 73, Number 10

3 Table 1. Operationalizing constructs examined in senior dental students in the Baby Oral Health Program Variable Definition Sample Questions Scoring Knowledge Overall familiarity with preventive 1. What determines the frequency Range: 0 1 (14 items) practices in early childhood and whereby an infant or toddler 0=incorrect epidemiology of infant and toddler should be seen by a dentist? 1=correct oral health. 2. For what condition are pacifiers Open-ended questions protective? Confidence Self-assurance about abilities to How comfortable are you : Range: 1 5 (11 items) provide proper infant and toddler 1. Dealing with a screaming and 1=very uncomfortable oral health care. crying infant or toddler? 5=very comfortable 2. Providing preventive services such as fluoride varnish on infants or toddlers? Opinions Beliefs and attitudes regarding How important do you feel it is : Range 1 5 (10 items) prevention and restorative needs for 1. For infants and toddlers to have 1=not at all important infants and toddlers. a dental home? 5=very important 2. To assess the presence of a pacifier or finger sucking habit in infants and toddlers? Behaviors Assessment of self-reported current How often do you : Range: 1 5 (11 items) and anticipated future practice 1. Counsel caregivers about their 1=never patterns. child s dental and physical 5=every appointment development? 2. Anticipate providing restorative treatment to 0 3 year olds? Start cohort, while those at the community health center were seen in conjunction with a pediatric well-child visit. At the beginning of each semester, students in both the control and intervention groups were ed on their infant and toddler oral health baseline knowledge, confidence, opinions, and behaviors (Table 1). Each construct was represented by an average score calculated by summing the items divided by the total number of items. Current and expected future behaviors were reported as one construct. At the conclusion of the rotation, the students completed the post-participation. Similarly, the control group completed identical s testing the same constructs as those at baseline and in a similar timeframe as the intervention group. A sample size calculation performed before the beginning of the study indicated that forty-one subjects per study arm would provide sufficient power ( 80 percent) to detect a moderate effect size (for example, a difference between groups of a two-point change, assuming a ten-point scale, from pre- to post-). Analysis was performed using SAS version 9 software. 9 The demographic characteristics of the intervention and control groups were compared using chi-square tests and the baseline average domain scores with unpaired t-tests. For each domain, analysis of covariance (ANCOVA) was used to compare the average post-scores of the two groups. The model included fixed effect of group, the baseline score as the covariate, the interaction of group and baseline domain score, and the explanatory variables: ability to speak Spanish, specialty after graduation, previous experience, and gender. The interaction term, if not statistically significant, was removed from the model. The level of significance was set at.05. Results The response rate was 84 percent, allowing for sufficient analytical power. Table 2 shows there was no statistical difference at baseline for a number of demographic variables in the intervention versus control groups. When examining the unadjusted comparison of composite scores for each outcome, there was a statistical difference favoring the pre- and post-scores for those students enrolled in the bohp intervention, as reflected by the higher score for each construct (Table 3). Knowledge demonstrated the largest post-score change (p<.01). A statistically significant interaction was found between baseline knowledge and the bohp inter- October 2009 Journal of Dental Education 1173

4 Table 2. Descriptive data for dental students participating in study, by number and percentage of specified group Total Group Intervention Group Control Group n=86 n=45 n=41 Gender Male 48 (56%) 23 (51%) 25 (61%) Female 38 (44%) 22 (49%) 16 (39%) Postgraduation plans General practice 41 (48%) 23 (51%) 18 (44%) Advanced training 45 (52%) 22 (49%) 23 (56%) Have children at home Yes 17 (20%) 9 (20%) 8 (20%) No 69 (80%) 36 (80%) 33 (80%) Spanish-speaking ability None to minimal 70 (81%) 38 (84%) 32 (78%) Some to fluent 16 (19%) 7 (16%) 9 (22%) Total Group Intervention Group Control Group Mean Score (SD) Mean Score (SD) Mean Score (SD) Age 28.4 (4.5) 28.5 (4.4) 28.3 (4.6) Previous rotation hours 22.0 (45.6) 19.4 (46.3) 25.0 (45.3) Average number of children 0.4 (0.8) 0.4 (0.8) 0.3 (0.8) Table 3. Construct comparing mean unadjusted pre- to post-score differences in the intervention and control groups Intervention Group Control Group Outcome Domains mean score change (SD) mean score change (SD) Knowledge 0.3 (0.2) 0.0 (0.1) Confidence 1.0 (0.7) 0.1 (0.4) Opinions 0.2 (0.3) 0.0 (0.4) Behavior 0.4 (0.8) 0.0 (0.5) vention, indicating that the relationship between the pre- and post-knowledge scores differed between the two groups (p<.0001). In the control group, a strong association was found between pre- and post-knowledge, while in the intervention group no correlation was evident. For all other constructs, no statistically significant interaction was found (p>.07). Participation in bohp was also a statistically significant predictor of the post-construct score for confidence, opinions, and behaviors after adjusting for the pre-scores and all other explanatory variables (p<.016). The adjusted post-scores are illustrated in Figure 2, revealing higher adjusted mean scores for the intervention versus the control group. Other factors were examined beyond the bohp intervention that might play a role in affecting students knowledge, confidence, opinions, and behaviors. For knowledge and behaviors, no factors beyond the intervention were significant. For confidence, students who had participated in a rotation caring for children less than three years of age prior to bohp, as well as those students reporting being able to speak Spanish at a conversational level or above, had higher adjusted average post-confidence scores than their counterparts. One other explanatory variable affecting the results was in the students opinions. Females had a higher adjusted average post-opinion score, indicating that females placed greater importance on infant and toddler oral health than did males. Discussion This study was the first to prospectively examine the change in dental students knowledge, confi Journal of Dental Education Volume 73, Number 10

5 Figure 2. Adjusted post-means and 95 percent confidence intervals for each construct October 2009 Journal of Dental Education 1175

6 dence, opinions, and behaviors after implementing an infant and toddler oral health program (bohp), while using a control group to assess the impact. The rotation positively and significantly influenced all constructs in relation to early oral health care, with the greatest effect observed with increased knowledge. The sustainability of these changes warrants future study. Also relevant were students previous experiences in infant and toddler oral health during dental education. Students who had treated and/or screened young children prior to bohp were more confident than those with bohp as their only opportunity to work with infants and toddlers during their training. This effect is similar to that in previous research. For example, medical students with multiple exposures to anesthesia-related clinical cases were found to have increased confidence in performing those procedures. 10 Such repeated exposures could be accomplished in a dental school setting with clinical experiences spread throughout the curriculum and enhanced with pediatric extramural rotations that include infant and toddler oral health as a component of patient care. The demographics of children and health care providers should be considered when implementing an infant and toddler oral health program. The Hispanic population in the United States is growing rapidly, with the U.S. Census Bureau estimating it to nearly double between 2010 and This trend was reflected in the large Spanish-speaking patient population seen during the bohp rotation. Better command of the Spanish language, as reported by each student, provided increased comfort and confidence for students and should be considered in dental curriculum development as we address equitable access to dental care that mirrors the current demographics. While translators were available, those who communicated directly with the patients had improved confidence in treating these patients and in speaking with their caregivers. This is supported by literature indicating that Hispanic patients report feeling that their physician does a better job of explaining, listening, spending an appropriate amount of time with the patient, showing respect, and assisting them with making informed decisions when the medical provider speaks the same language as the patient (English vs. only Spanish). 12 Similarly, gender played a role in our results, with female students placing more emphasis on infant and toddler oral health than their male counterparts. This is not surprising, as females are more often primary caregivers for children at this age. Other studies have shown that men often perceive their role as more of a supporter and overseer than a direct caregiver. This difference often results in the mother being the primary decision maker about the child and may result in females being more likely to emphasize early oral health care. 13,14 The findings of this study need to be considered in the context of its limitations. Although students were assessed for similarities at baseline, they were not randomly selected. Rather, they showed a desire to gain this experience or needed to complete this rotation in order to meet their requirements for graduation. Furthermore, limitations inherent in the inclusion of assessments were noteworthy. In summary, bohp was a feasible program to implement into the dental school curriculum. In its short time, the bohp rotation has been well received by students, patients, and their families. Among dental students, the majority (89 percent) reported that they would be more likely to provide care to children under the age of three following this exposure. Consisting of approximately eighteen hours of instruction time, the bohp rotation translates into a one-credit-hour course in the University of North Carolina s dental school curriculum. The current curriculum involves approximately 232 course hours over four years. Thus, including this instruction in the curriculum would increase the curriculum time by less than 0.5 percent. It is possible that, with a small shift in dental school curricula, this underserved population could become far better served, although the long-term effects of this intervention will need to be confirmed. To date, nearly half of all senior dental students participate in the rotation, and it is the goal of the department that all dental students rotate through the program as a way to help broaden the safety net for early childhood oral health. REFERENCES 1. Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics 2004;114(4): Edelstein BL, Manski RJ, Moeller JF. Pediatric dental visits during 1996: an analysis of the federal Medical Expenditure Panel Survey. Pediatr Dent 2000;22(1): Centers for Disease Control and Prevention. Trends in oral health status: United States, and Washington, DC: U.S. Department of Health and Human Services, U.S. Census Bureau. Annual estimates of the population by five-year age groups and sex for the United States: 1176 Journal of Dental Education Volume 73, Number 10

7 April 1, 2000 to July 1, At: national/asrh/nc-est2006-sa.html. Accessed: February 26, American Academy of Pediatric Dentistry. About AAPD: membership statistics. At: Accessed: March 28, Seale NS, Casamassimo PS. Access to dental care for children in the United States: a of general practitioners. J Am Dent Assoc 2003;134(12): Cotton KT, Seale NS, Kanellis J, Damiano PC, Bidaut- Russell M, McWhorter AG. Are general dentists practice patterns and attitudes about treating Medicaid-enrolled pre-school age children related to dental school training? Pediatr Dent 2001;23: McWhorter AG, Seale NS, King SA. Infant oral health education in U.S. dental school curricula. Pediatr Dent 2001;23(5): SAS SAS Release 9.1. SAS Institute Inc., Cary, NC, USA. 10. Morgan PJ, Cleave-Hogg D. Comparison between medical students experience, confidence, and competence. Med Educ 2002;36(6): U.S. Census Bureau. Projected change in population size by race and Hispanic origin for the United States: 2000 to At: files/nation/summary/np2008-t7.xls. Accessed: April 12, Wallace LS, Devoe JE, Heintzman JD, Fryer GE. Language preference and perceptions of healthcare providers communication and autonomy making behaviors among Hispanics. J Immigr Minor Health, September 24, 2008 [E-pub ahead of print]. 13. Liberg B. The birth of premature infants: experiences from the fathers perspective. J Neonatal Nurs 2007;13(4): Deeney K, Lohan M, Parkes J, Spence D. Experiences of fathers of babies in intensive care. Paediatr Nurs 2009;21(1):45 7. October 2009 Journal of Dental Education 1177