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ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 2  |  Page : 197-201

Knowledge, attitude and practices of pediatricians regarding malocclusion in Haryana, India


1 Department of Orthodontics and Dentofacial Orthopedics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India
2 Department of Orthodontics and Dentofacial Orthopedics, Kalka Dental College, Meerut, Uttar Pradesh, India
3 Department of Orthodontics and Dentofacial Orthopedics, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India

Date of Web Publication10-Jun-2016

Correspondence Address:
Rekha Sharma
Department of Orthodontics and Dentofacial Orthopedics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.183803

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  Abstract 


Introduction: Pediatricians are often the first health professional whom children visit but very few patients have presented in the orthodontic clinics with referrals from pediatricians, an indication that the primary caregivers may be deficient in the knowledge and skill to recognize cases requiring orthodontic intervention. Aim: To explore the knowledge, attitude, and practices of pediatricians regarding orthodontics. Materials and Methods: A questionnaire survey of 40 questions was conducted among pediatricians in Haryana. A cross-sectional, questionnaire-based study was conducted between January 2015 and June 2015 (6 months) among 198 pediatricians practicing in Haryana state, India. Statistical Analysis: Statistical analysis was performed using SPSS software (version 19, SPSS Inc., Chicago, IL, USA). Frequency distribution and measures of central tendency were generated for all numerical values, and descriptive and inferential analysis was done using Chi-square test. Results: Knowledge level among the study participants was low. Although a majority (84.9%) agreed for a need for oral health assessment during general examination of the children in practice less than half (41%) did so citing problems, the lack of adequate training being the most common (41%). Conclusions: The need for more education of the pediatricians regarding orthodontics was perceived. Effective and appropriate involvement of pediatric primary care clinicians can be expected only after they receive the appropriate training and encouragement and problems with the dental referral environment are addressed.

Keywords: Attitude, knowledge, malocclusion, orthodontics


How to cite this article:
Sharma R, Kumar S, Singla A, Kumar D, Chowdhary S. Knowledge, attitude and practices of pediatricians regarding malocclusion in Haryana, India. J Indian Assoc Public Health Dent 2016;14:197-201

How to cite this URL:
Sharma R, Kumar S, Singla A, Kumar D, Chowdhary S. Knowledge, attitude and practices of pediatricians regarding malocclusion in Haryana, India. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Oct 13];14:197-201. Available from: http://www.jiaphd.org/text.asp?2016/14/2/197/183803




  Introduction Top


The specialty of orthodontics relates to facial and occlusal development and involves prevention, interception, and correction of occlusal and dentofacial anomalies known as malocclusion.[1] Children form a major chunk of orthodontic patients. Hence, the pediatric health-care professionals, who are more likely to encounter children during their developing years can play an important role in the preventive and interceptive aspects of malocclusion if they are able to make appropriate decisions about referring children to a dentist for effective interventions.[2] Such referrals at the proper time can result in a huge difference in treatment results, even obviating the need for orthodontic treatment in few cases. However, most patients in the orthodontic clinic are usually self-referred; this is worrying given that a larger proportion of the population visits the doctor more often than they visit the dentist, especially in a developing country like India.

Thus, our decision to explore the knowledge of pediatricians on orthodontics was because the poor referral might not be unconnected with poor knowledge of orthodontics and the low ability to recognize cases requiring orthodontic intervention. Although few studies have been reported on dental screening and referral by pediatricians, and the effectiveness of their dental caries preventive activities. To the best of our knowledge, no such study has been conducted for orthodontic referrals.[3],[4] The purpose of this study was to determine the knowledge, attitude, and practices of pediatricians regarding malocclusion in Haryana, India.


  Materials and Methods Top


A cross-sectional questionnaire-based study carried out between January 2015 and June 2015 (6 months) among pediatricians practicing in Haryana state, India. Ethical clearance was taken from the Institutional Ethical Committee.

The survey instrument, a self-administered questionnaire, was specifically designed by the researchers for this study. The survey instrument consisted of 40 questions divided into 3 parts: The first part (8 questions) obtained information on demographic data, previous dental experience, and sources of information about dentistry. The second part (18 questions) examined the respondent's knowledge of orthodontics as a specialty and included questions such as what is orthodontics, signs and features of orthodontic problems, what procedures are carried out in an orthodontic clinic, and etiology of orthodontic problems. The third part examined (14 questions) the practices adopted by the pediatricians in their practices for orthodontic problems and their attitude toward their management. The instrument was pretested for construct validity (Average congruency percentage - 92%) and reliability (r = 0.82) on 20 pediatricians before final data collection and necessary modifications were made based on the results of the pretest.

The list of pediatricians practicing in Haryana state was obtained from the Indian Academy of Pediatrics Haryana Directory.[5] There were 476 listed members. Systematic random sampling was used, and every 2nd member was selected for participation in the study. The selected pediatricians were contacted on telephone and explained about the survey by the principal investigator and their verbal consent for participation in the study was taken. A total of 238 questionnaires were subsequently mailed to them, of which, 198 were properly completed and returned, giving a response rate of 83.19%.

Statistical analysis

Statistical analysis was performed using the Microsoft Office Excel 2007 and SPSS software (version 19, SPSS Inc., Chicago, IL, USA). Frequency distribution was generated for all variables and measures of central tendency were generated for all numerical values. Descriptive and inferential analysis was done using Chi-square test at P < 0.05.


  Results Top


The respondent's age range was 25–67 years with mean (standard deviation) of 36.19 (12.06). Majority of them (78.8%) were males, whereas 21.2% were females. About 52% were in private practice, whereas 48% were working in academic institutes. The average number of patients seen in a day was 37 [Table 1].
Table 1: Sociodemographic features of study participants

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Large percentages 89.9% of pediatricians were familiar with the term orthodontics and 93.9% knew what malocclusion means. About two-third (72.5%) correctly identified the appliances used in orthodontics though 12.5% selected dentures. The symptoms of malocclusion were correctly identified by 80.5% as alteration in the alignment of teeth/or appearance of face. However, 29% recommended treatment for spacing in the primary teeth. Only 59% could identify the normal relation between maxillary and mandibular teeth. Less than half of the respondents (45.5%) did not know about the need and appropriate age for the first orthodontic examination [Table 2].
Table 2: Response of the study participants regarding the knowledge of orthodontics

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Although 86.5% acknowledged that some malocclusions can be prevented 50.6% thought prevention can be delayed till permanent dentition and even later. Majority (82.8%) agreed that pediatricians have a role in identifying and preventing malocclusion, and 84.9% felt that every pediatrician should look into the occlusion during routine examination of tonsils and pharynx. However, at the same time, 41% felt identifying malocclusion is difficult, and >50% agreed there is a little time for the same due to busy practice. A large majority (99%) felt the need for collaboration with dentist/orthodontist and 82.5% felt the children with malocclusion should be immediately referred to orthodontist.

Although 91.9% said that they come across a patient with malaligned teeth, but only 56.6% referred them to a dentist. Only less than one-third participants (24.2%) referred one to five patients in the last month, 7.1% participants referred six to ten patients in the last month, and 31.3% do not remember sending any patients in the last month. Patients with protruded upper anterior teeth were referred by 27.3% participants, whereas 39.4% participants referred patients with crowding of anterior teeth and 8.1% participants referred patients with cross bite. A large number of respondents (70.7%) did not recall identifying or referring any patient with habits [Table 3]. Only 45% acknowledged receiving knowledge of orthodontics and malocclusion during their graduation and none through scientific journals [Figure 1]. Other sources of information included friends, colleagues, and through dentists. Majority (87.5%) agreed that optimum use of dental posting during graduation (M.B.B.S course) is not made.
Table 3: Attitude and practices adopted by the pediatricians

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Figure 1: Participants' sources of information on preventive oral care

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Almost all participants (96.7%) felt that their knowledge of dentistry in general and orthodontics in particular was inadequate, and they were interested in having more information about oral disease prevention [Figure 2]. The level of knowledge regarding malocclusion did not vary with any of the demographic features studied; however, significant differences were found in the attitude and practices of pediatricians regarding orthodontic patients with relation to age and practice setting. Significantly (P< 0.05) large number of patients was referred to dentist/orthodontist by pediatricians above the age of 35 years. Statistical significant variation (P< 0.05) was found in the percentage of orthodontic referrals by private practitioners and those working in teaching hospitals.
Figure 2: Need for more information

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  Discussion Top


Most people associate orthodontics with “braces,” however in an ideal orthodontic setup <50% of cases should consist of full corrective mechanotherapy (braces), whereas 10% of cases require only observation and preventive procedures, 20% interceptive orthodontics and 25% partial corrective mechanotherapy.[6] It is here that medical practitioners and especially pediatricians can play an important role since they are more likely to be visited by children during the period when preventive, interceptive, and partial corrective orthodontic procedures can be carried out. However, we find that very few patients in our clinics come from medical referrals thus missing out on these important opportunities of prevention and interception. We assumed that the poor referral may be because of limited knowledge of orthodontics as a specialty among medical doctors or the fact that they are unaware of the impact of malocclusion (orthodontics) on the health and general well-being of the patient. A timely referral can result in a huge difference in treatment results, even obviating the need for orthodontic treatment in few cases and need for less drastic measures in few others.

We found insufficient levels of knowledge among the studied pediatricians which may have affected their practice of oral health. In this study, only 45% acknowledged receiving knowledge of orthodontics and malocclusion during their graduation, and none through scientific journals which indicate the material regarding orthodontics and malocclusion is meager in pediatric scientific journals.

While pediatricians agree they should become more involved in oral health assessment and care and regularly express their willingness to do so in surveys. The study revealed that 84.9% of pediatricians said that they should examine the patient's oral cavity. However, in practice, only 41% of the pediatricians perform oral health assessment routinely during physical examination. By routine examination of the oral cavity during physical examination, pediatricians can diagnose early dental problems including malocclusion, and the child can be referred appropriately.

In the present study, 41% of survey respondents cited their lack of training on how to correctly perform screening dental examinations on young children and to educate families on preventive oral health as the most common barrier to their participation in oral health-related activities. Only 38.4% reported having received oral health education in medical school, residency, or continuing education. A previous study of pediatricians regarding pediatric preventative dental care has concluded that respondents received 2 h or less of preventive dental education during medical and specialty training.[7]

Another study of pediatricians reported that 13.4% felt their knowledge of the oral cavity and the developing dentition was excellent, 18% felt it was good, and 19.6% felt it was adequate.[8] In our study, also 96.7% felt the need for more information in this regard.

Most pediatricians who participated in this study referred patients to dentists only when there was an explicit dental complaint, whereas the American Dental Association guidelines, endorsed by the American Association of Pediatricians, states that the first examination is recommended at the time of the eruption of the first tooth and no later than 12 months of age.[9] The American Association of Orthodontists recommends that all children have a checkup with orthodontic specialist not later than age 7. As per these guidelines, each child should be sent for an orthodontic examination by 7 years of age, which in the present study was acknowledged by only 45.5%. We are not aware whether such guidelines are issued by the Indian association of pediatricians.

At some point in the evolution of caring for people, care for our teeth and gums was separated from care for the rest of the body. As a consequence, for centuries, medical doctors have taken care of people's physical health but have skipped over their teeth and headed straight to the back of the throat.[10] Furthermore, orthodontic problems are generally not associated with high mortality or morbidity; hence, they tend to be overlooked by most health professionals as less important. However, studies indicate that malocclusion has a significant impact on the psychosocial health of the affected person; hence, there is a need to bring more focus on the appropriate referral and prompt management of persons with occlusal disharmony.[11]

The lesser orthodontic referrals by pediatricians below 35 years of age might be related to the stressful/busy life schedule of the present times as not having sufficient time is cited as one of the major factors by pediatricians of inadequate referral of orthodontic patients.

The higher referrals of patients by pediatricians working in teaching hospitals might be related to easy availability of expert dental/orthodontic opinion as most of the teaching hospitals usually have a dental hospital/dental wing attached to it. This again highlights another important issue found in this study wherein pediatricians have acknowledged the need of more collaboration between pediatricians and orthodontists and have pointed out practical problems in the same.

The main strength of our study is that it has emphatically pointed that despite the progress in many areas of dentistry in general and orthodontics in particular, the one sore point is the lack of awareness of this specialty. Majority of the respondents believe that they should refer patients who require orthodontic treatment to the orthodontist and would do so if they had any patients requiring orthodontic treatment. This high number justifies the need for proper orthodontic awareness among pediatricians to ensure appropriate referral patterns and points to the need for more efforts on our part by organizing more public health awareness programs, CDE programs, writing on dental topics in medical journals, etc.

The study is not without limitations. First, the sample size is small, and therefore the results cannot be generalized. Furthermore, cross-sectional studies are often limited by respondent bias, but they can serve as impetus for further studies in this area. There is limited research conducted in this area; in fact, we could not find a single Indian study of this kind; hence, it was difficult to make any comparisons.

Further studies can be done on a larger sample size and also differentiating between the rural–urban and metropolitan pediatric practice settings thus being more specific in identifying areas to focus on bringing this change in awareness.


  Conclusions Top


Knowledge level among the study participants was low. The need for more education of the pediatricians regarding orthodontics was perceived. It would help them to identify malocclusions in their patients and increase the awareness regarding its management among their patients. Improving the awareness among the practitioners in this area can help the patients with malocclusion to be referred for orthodontic treatment at initial stages; this can prevent treatment requirements in many cases or decrease the severity of treatment measures required. Effective and appropriate involvement of pediatric primary care clinicians can be expected only after they receive the appropriate training and encouragement and problems with the dental referral environment are addressed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Adegbite K, Ogunbanjo B, Ajisafe O, Adeniyi A. Knowledge of orthodontics as a dental specialty: A preliminary survey among LASUCOM students. Ann Med Health Sci Res 2012;2:14-8.  Back to cited text no. 1
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Moorrees CF, Sisson WR, Peckos PS, Christie RG, Baldwin DC Jr. Need for collaboration of pediatrician and orthodontist. Pediatrics 1962;29:142-7.  Back to cited text no. 2
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Murthy GA, Mohandas U. The knowledge, attitude and practice in prevention of dental caries amongst pediatricians in Bangalore: A cross-sectional study. J Indian Soc Pedod Prev Dent 2010;28:100-3.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
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Peedikayil FC, Kottayi S, Kenchamba V. Knowledge, attitude and practices of pediatricians regarding prevention of dental caries. Health Sci 2013;2:JS002.  Back to cited text no. 4
    
5.
Goyal A, Agarwal AK. Indian Academy of Paediatrics, IAP Haryana Directory; 2010. [Last accessed on 2015 Jan 10].  Back to cited text no. 5
    
6.
Graber TM, editor. Preventive orthodontics. In: Graber's Text Book of Orthodontics, Basic Principles and Practice. 3rd ed. Philadelphia: Elsevier; 2001. p. 627-40.  Back to cited text no. 6
    
7.
Sánchez OM, Childers NK, Fox L, Bradley E. Physicians' views on pediatric preventive dental care. Pediatr Dent 1997;19:377-83.  Back to cited text no. 7
    
8.
Tsamtsouris A, Gavris V. Survey of pediatrician's attitudes towards pediatric dental health. J Pedod 1990;14:152-7.  Back to cited text no. 8
    
9.
American Academy of Paediatrics. Children's Oral Health. Available from: http://www. 2.aap.org/commpeds/dochs/oralhealth/index.html. [Last accessed on 2016 Apr 06].  Back to cited text no. 9
    
10.
Braun PA. Pediatricians are the gatekeepers of children's oral health. Contemp Pediatr 2013;30:8-11. Available from: http://www.contemporarypediatrics.modernmedicine.com/contemporary -pediatrics/content/tags/american-academy-pediatrics/pediatricians-are-gatekeepers-child. [Last accessed on 2016 Apr 06].  Back to cited text no. 10
    
11.
Dorsey J, Korabik K. Social and psychological motivations for orthodontic treatment. Am J Orthod 1977;72:460.  Back to cited text no. 11
    


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