According to the American Speech-Language-

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1 Knowledge, Attitudes, and Practices of Pediatric Dentists Regarding Speech Evaluation of Patients: Implications for Dental Education Lisa Van Eyndhoven, DDS, MS; Steven Chussid, DDS; Richard K. Yoon, DDS Abstract: The aim of this cross-sectional study was to determine pediatric dentists attitudes about speech evaluation in the dental setting and assess their knowledge of speech development and pathology. In October 2013, members of the American Academy of Pediatric Dentistry were invited to participate in an electronic questionnaire. Categories of questions were demographics, attitudes and confidence in speech pathology, and theoretical and practical knowledge of speech development and speech pathology. Theoretical knowledge was assessed using questions about phonetics and speech milestones. Practical knowledge was determined with three 30-second interview-style video clips. A total of 539 responses were received for a response rate of 10.4%. The majority of respondents reported feeling that speech evaluation should be part of the pediatric dental visit (72.8%) and felt confident in their ability to detect speech issues (73.2%). However, they did poorly on the theoretical knowledge questions (41.9%) as well as the practical knowledge questions (8.5%). There was a statistically significant difference in theoretical score between gender and type of occupation (p<0.05). This difference was not observed when examining practical knowledge. This study suggests that although pediatric dentists are in an ideal position to aid in the detection of speech issues, they currently have insufficient training and knowledge to do so. Dr. Van Eyndhoven is an associate pediatric dentist in private practice, New York, NY, and former postdoctoral resident fellow, Columbia University Medical Center; Dr. Chussid is Associate Professor of Dental Medicine and Chair, Section of Growth and Development, Columbia University Medical Center; and Dr. Yoon is Associate Professor of Dental Medicine and Program Director, Advanced Specialty Education in Pediatric Dentistry, Columbia University Medical Center. Direct correspondence to Dr. Richard K. Yoon, Columbia University College of Dental Medicine, 630 W. 168 th Street, New York, NY 10032; ; rky1@cumc.columbia.edu. Keywords: advanced dental education, graduate dental education, pediatric dentistry, speech, pathology, oral examination, continuing education Submitted for publication 1/23/15; accepted 5/12/15 According to the American Speech-Language- Hearing Association (ASHA), approximately 17% of Americans suffer from a communication disorder, and about 7% of children have specific language impairment. 1 Early identification of speech disorders is important because they may progress to lifelong communicative impairments if left untreated. Often a precursor for learning disabilities, there is a concurrence between speech disorder and autism, behavior disorders, and neurologic impairments. 2 Language issues can also lead to problems with self-esteem and maladaption of emotional and social reactions. 3 According to ASHA, early speech and language intervention with expressive language and vocabulary issues has a positive effect. 1 Although this connection suggests that early diagnosis is beneficial to the child, most speech pathology is in fact not recognized until school age. To aid in the early identification of children with speech issues, speech language pathologists (SLPs) work with physicians, occupational therapists, and early childhood educators. 4 However, there is currently little interaction between SLPs and pediatric dentists. Basic speech and language milestones are available in the Handbook of Pediatric Dentistry published by the American Academy of Pediatric Dentistry (AAPD) although it is unclear how much knowledge pediatric dentists have in this field or have received during their clinical training. 5 Furthermore, it is unclear how much speech and language training pediatric dentists receive in their specialty through continuing education. Awareness of speech delay and speech pathology can aid pediatric dentists in determining the best way to treat a child, not only in treatment planning but also in behavior management. 6 A firm understanding of the linguistic maturity of the child helps pediatric dentists adjust their techniques to reduce miscommunication, which has been linked to misbehavior. 7 November 2015 Journal of Dental Education 1279

2 While pediatric dentists play a critical role in evaluation of the developing oral structures and the diagnosis of oral pathology in the young child and also rely heavily on communication to perform adequate treatment, it is unclear what their role should be in the diagnosis, referral, and treatment of speech pathology. The aims of this cross-sectional study were therefore to 1) determine pediatric dentists attitudes about training in speech and language pathology; 2) determine their attitudes regarding incorporation of speech evaluation in the routine dental examination; and 3) evaluate their knowledge of normal speech development and speech pathology. Methods All study procedures and waiver of consents were approved by The Research Compliance and Administration System at Columbia University Medical Center, protocol number AAAL4850. The research team developed and beta tested a survey instrument. Survey testing was accomplished with 12 pediatric dentists (eight in clinical practice and four in academe) with various years of clinical experience. The beta test was used to clarify and refine survey questions and eliminate unclear items. In October 2013, 5,200 active non-retired members of the AAPD who had graduated from a postdoctoral program in the U.S. or abroad were invited via to participate in a 33-item electronic questionnaire hosted and administered by Qualtrics Survey Software and Research Suite (Qualtrics, Provo, UT, USA). Questionnaire items contained questions regarding demographics, attitudes and confidence in speech pathology, and theoretical knowledge and practical knowledge of speech development and speech pathology. Demographic questions asked about respondents gender, birth year, race/ethnicity, type of postdoctoral program attended, year of graduation from program, diploma obtained, occupation, and training in speech pathology including participation in a craniofacial team. Survey recipients were asked how confident they felt in their training in speech pathology and whether they felt confident in their ability to identify speech issues. Attitudes were determined by inquiring about the respondents interest in attending continuing education courses in speech pathology, how strongly they agreed with the incorporation of speech pathology in dental training (predoctoral and postdoctoral), and how they felt about the incorporation of speech evaluation in the dental recall examination. Theoretical knowledge was assessed with questions about phonetics, speech and oral milestones (e.g., drooling and swallowing), and speech therapy. These questions were derived from the AAPD handbook and the American Academy of Pediatrics (AAP) Bright Futures guidelines. 5,8 Practical knowledge was assessed with three 30-second interview-style video clips obtained from a video-sharing web-based server. The first video featured a three-year-old girl with apraxia (a speech production disorder), the second a normally developing four-year-old girl, and the third a ten-year-old boy with autism and social language impairment. Participants were asked whether the child would benefit from a referral to an SLP and to identify any speech issues if any. All videos and questions were reviewed and verified by a registered SLP on the craniofacial team. The respondents remained anonymous, and no identifying information was obtained. Descriptive statistical analysis was conducted using the Qualtrics web-based survey and SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) to generate percentages, t-tests, ANOVA, and linear regression analysis. Statistical significance was set at Results A total of 539 responses were received for a response rate of 10.4%. Approximately 50% of the respondents identified themselves as female (N=278), and the majority (75.7%, N=408) identified as being white/caucasian with the second most predominant ethnic group being Asian (10.2%, N=55). Ages varied from <30 years (5%), years (38%), to years (22%); the remaining respondents were above the age of 50. Approximately 40% had graduated from their postdoctoral program after 2005, and 53% graduated from a hospital-based program affiliated with a dental school. During their postdoctoral program, 70% had participated in a craniofacial team. The majority of the respondents (87.6%, N=472) reported their primary occupation as clinical practice, with the majority in practice in a private dental office (81.0%, N=437). Of the remaining respondents, 51% identified themselves as dental educators (N=51); only one reported being a dental researcher. Approximately 73% of the responding pediatric dentists agreed that speech evaluation should 1280 Journal of Dental Education Volume 79, Number 11

3 be part of the routine pediatric dental examination, and 73.2% said they felt confident in their ability to identify speech delays in the clinical pediatric dental setting. While 95.4% reported feeling that training in speech and language development was important during their postdoctoral program, only 41.2% felt their training sufficiently prepared them to identify common speech pathologies. In addition, 45.1% said they were likely to attend a continuing education course in speech pathology (Table 1). The average score of correctly answered theoretical questions was 41.9%, and less than 1% of the respondents correctly identified all speech and oral milestones. Only 8.5% provided correct referrals to an SLP to all three children in the videos, while only 2.8% correctly identified speech issues (if any) in the three children (Table 1). There was a statistically significant difference in theoretical score between type of occupation and gender. The average theoretical score for clinical pediatric dentists was 4.08 (out of a possible 12), and the average theoretical score for pediatric dentists who identified themselves as dental educators/dental researchers/other was 5.27 with a mean score difference of 1.19 (p<0.05). This difference was not observed when comparing practical knowledge scores (Figure 1). The average theoretical score for female pediatric dentists was 4.57 (out of a possible 12), and the average theoretical score for male pediatric dentists was 3.95 with a mean score difference of 0.62 (p<0.05). This difference was not observed when comparing practical knowledge scores (Figure 2). There was no statistically significant correlation between theoretical or practical score with regard to race or ethnicity, type of postdoctoral program, or graduation year. Exposure to speech pathology training in either postdoctoral training or via a continuing education course led to an increase in theoretical and practical knowledge, but this increase was not statistically significant (Figure 3). There was also no statistically significant difference in one-way ANOVA analysis of the effect of quantity of training in speech pathology on theoretical and practical knowledge. Discussion Speech is produced when sounds are formed by the vocal chords and are altered by the movement of the lips, tongue, and teeth. Speech therapists identify problems with this process and diagnose delays and pathologies such as apraxia, dysarthria, and articulation disorders. They use various techniques to overcome these issues and also collaborate with other health care professionals such as pediatricians and physicians who specialize in ear, nose, and throat as well as occupational therapists and early childhood educators. Predy and Meintzer reviewed the role of speech evaluation in the well-child visit with the pediatrician/family physician in They described how speech and language development is often a precursor for learning disabilities and that most speech pathology is not recognized until school age. Since such issues can lead to problems with self-esteem and maladaption of emotional and social reactions and since the family physician is often the first person consulted about speech issues, they argued that there should be greater awareness of speech evaluation on the part of the family physician. The meta-analysis done by Law et al. concluded that there was a positive effect of speech and language therapy interventions for children with expressive phonological and vocabulary issues. 2 They Table 1. Descriptive data for attitudes and knowledge of participating pediatric dentists Number (Total Respondents) Percentage Attitudes Likely to attend a continuing education course in speech pathology 243 (539) 45.1% Agreed that training in speech pathology should be part of postdoctoral training 501 (525) 95.4% Theoretical knowledge Average of correctly answered theoretical questions 226 (539) 41.9% Participants who correctly identified all speech and oral milestones 3 (539) 0.6% Practical knowledge Participants who provided correct referrals to children from the videos 46 (539) 8.5% Participants who correctly identified any speech issues in children from the videos 15 (539) 2.8% November 2015 Journal of Dental Education 1281

4 Figure 1. Mean theoretical and practical scores of participating clinical pediatric dentists in comparison with dental educators/researchers/other Note: Scores on both theoretical and practical questions are out of a possible 12. *Mean score difference=-1.19 (p<0.05) Figure 2. Mean theoretical and practical scores of participating female pediatric dentists in comparison with male pediatric dentists Note: Scores on both theoretical and practical questions are out of a possible 12. *Mean score difference=-0.62 (p<0.05) 1282 Journal of Dental Education Volume 79, Number 11

5 Figure 3. Mean theoretical and practical scores of participants with and without formal training in postdoctoral program or continuing education courses Note: Scores on both theoretical and practical questions are out of a possible 12. No statistically significant difference was found. also described a concurrence between speech disorder and autism, behavior disorder, and neurologic impairment. This relationship suggests that early diagnosis and treatment in certain circumstances would benefit the child. Lawrence and Bateman in their literature review described a 12-minute method that would aid in early diagnosis and can be incorporated into any pediatric practice. 4 Dentists learn how the proper alignment of teeth helps with the phonation. Disciplines such as prosthodontics and orthodontics address these structural issues to help aid functional ones. Both Fawcus and Hopkin described the effect of malocclusions and skeletal disharmony on speech development. 9,10 Those studies promoted the role of the orthodontist through the use of interceptive and traditional orthodontics in combination with speech therapy to guide the speech development of the child. Pediatric dentists are trained in how the oral structures of a child develop. They are aware in how they can affect these structures. For instance, the early extraction of primary incisors can affect speech pro- duction. 11,12 This connection suggests a larger role for the pediatric dentist in the detection of early speech pathology. Since pediatric dentists are involved in treating young children and since communication is essential for cooperation and effective treatment, they are in a good position to help identify any delays. 6 Awareness of speech delay and speech pathology can aid pediatric dentists in determining the best way to treat a child. For instance, Pinkham describes how misbehavior is often linked to miscommunication. 7 A better understanding of the linguistic maturity of their patients will help pediatric dentists determine the child s behavior in a treatment setting, allowing them to adjust their behavior management techniques. Since pediatric dentists have such a direct impact on the developing dentition and also play such a pivotal role in the overall development of the child, they should be more aware of language milestones and language disorders. Though most pediatric dentists (73.2%) in our study said they were confident in their ability to diagnose speech issues, on average they did not perform November 2015 Journal of Dental Education 1283

6 well on either the theoretical or the practical speech pathology questions. Pediatric dentists performed the best on the section analyzing knowledge of speech therapy and oral milestones (such as drooling and swallowing) with an average score of 48.9%, while they performed the worst on the section evaluating knowledge of phonemes and phonetics (22.6%). It was expected that they would perform well on the section of speech and language milestones since those are listed in the AAPD handbook; however, the average score was a 30.2% with only 13.1% of the sample scoring higher than 50%. There was no statistically significant correlation between theoretical or practical score and ethnicity, type of postdoctoral program, graduation year, or exposure to speech pathology in continuing education, postdoctoral, or predoctoral courses. It appears that the pediatric dentists were unilaterally unprepared to detect speech issues, and their race/ ethnicity, type of training they received, or amount of clinical experience seemed to have no impact on their ability to do so. There was a statistically significant difference in theoretical score between gender and type of occupation. The average theoretical score for clinical pediatric dentists was 4.08 (out of a possible 12), and the average theoretical score for pediatric dentists who identified themselves as dental educators/ dental researchers/other was 5.27, for a mean score difference of 1.19 (p<0.05). This difference was not observed when comparing practical knowledge scores (Figure 1). The average theoretical score for female pediatric dentists was 4.57 (out of a possible 12), and the average theoretical score for male pediatric dentists was 3.95, for a mean score difference of 0.62 (p<0.05). This difference was not observed when comparing practical knowledge scores (Figure 2). In general, participants with training in speech pathology either in postdoctoral education or continuing education courses did better on both theoretical and practical portions although the difference was not statistically significant (Figure 3). The limitations to this study were primarily the small number of participants. With a 10.4% response rate, this study represents only a small proportion of pediatric dentists in the United States. In addition, technical difficulties further limited the usable sample size. The electronic questionnaire had both embedded video-sharing web-based clips and links to the videos and due to limitations of various software programs, a large number of respondents were unable to view the videos and therefore unable to answer the questions pertaining to them. Though this problem further reduced the amount of usable data, the use of embedded electronic media has the ability to enhance both education and evaluation. Conclusion Because pediatric dentists are in a good position to detect early speech pathology, the aim of this study was to determine their attitudes about speech evaluation in the dental setting and assess their knowledge of speech development and pathology. Although only 10.4% of the total sample (members of the American Academy of Pediatric Dentistry) participated in the survey, the results suggest that pediatric dentists have insufficient knowledge and training to evaluate their patients speech development and pathology. However, while the participants performance on both the theoretical and practical evaluations was poor, the majority agreed that training in speech pathology is an important component of the education of the pediatric dentist. They also agreed that speech evaluation should be in the diagnostic scope of the pediatric dentist and should be a part of the dental examination. Disclosure The authors reported no conflicts of interest. REFERENCES 1. American Speech-Language-Hearing Association. Speech language pathology: medical review guidelines incidence and prevalence of communication disorders and hearing loss in children At: Accessed 4 Sept Law J, Garrett Z, Nye C. Speech and language therapy interventions for children with primary speech and language delay or disorder. Cochrane Database Syst Rev 2003(3). 3. Predy G, Meintzer J. Communication disorders in children: the role of the family physician. Can Fam Physician 1982;28: Lawrence R, Bateman N. 12 minute consultation: an evidence-based approach to the management of a child with speech and language delay. Clin Otolaryngol 2013;38(2): Nowak AJ, Casamassimo PS. American Academy of Pediatric Dentistry handbook of pediatric dentistry. 4th ed. Chicago: American Academy of Pediatric Dentistry, Shetty P. Speech and language delay in children: a review and the role of a pediatric dentist. J Indian Soc Pedod Prev Dent 2012;30(2): Journal of Dental Education Volume 79, Number 11

7 7. Pinkham JR. Linguistic maturity as a determinant of child patient behavior in the dental office. J Am Dent Assoc 1977;94(4): American Academy of Pediatrics. Bright futures tool and resource kit At: tool_and_resource_kit.html. Accessed 4 Sept Fawcus R. Dental problems in speech pathology. Proc R Soc Med 1968;61(6): Hopkin GB. Orthodontic aspects of the diagnosis and management of speech defects in children. Proc R Soc Med 1972;65(4): Adewumi A, Horton C, Guelmann M, et al. Parental perception vs. professional assessment of speech changes following premature loss of maxillary primary incisors. Pediatr Dent 2012;34(4): Lamberghini F, Kaste L, Fadavi S, et al. An association of premature loss of primary maxillary incisors with speech production of bilingual children. Pediatr Dent 2012;34(4): November 2015 Journal of Dental Education 1285