|Year : 2021 | Volume
| Issue : 1 | Page : 71-75
Knowledge, opinion, values, and practice of sealant use among dental practitioners in Bangalore city
Imran Pasha Mohammed1, Bushra Naaz Fathima Jaleel2, Umme Amarah3, SS Hiremath4, C Manjunath2, Archana Krishnamoorthy2
1 Department of Public Health Dentistry, Yenepoya Dental College, Mangalore, Karnataka, India
2 Department of Public Health Dentistry, The Oxford Dental College, Bengaluru, Karnataka, India
3 Department of Oral Medicine and Radiology, Yenepoya Dental College, Mangalore, Karnataka, India
4 Department of Public Health Dentistry, Government Dental College, Bengaluru, Karnataka, India
|Date of Submission||02-May-2020|
|Date of Acceptance||11-Feb-2021|
|Date of Web Publication||31-Mar-2021|
Imran Pasha Mohammed
Department of Public Health Dentistry, Yenepoya Dental College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Recent Cochrane review has recommended sealants in preventing occlusal caries in children and adolescents but its use in clinical practice is still underutilized all over the world. Aim: The aim was to assess knowledge, opinion, values, and practice among dental practitioners in Bangalore city. Materials and Methods: A cross-sectional study was conducted with a convenience sampling of 312 general dental practitioners (GDP) in Bangalore city. The data was collected using an anonymous, self-reporting 5-point Likert-scaled questionnaire by Martin et al., and analyzed using SPSS version 21 and ANOVA and t-test was utilized for analyzing the results P < 0.05 was regarded as significant. Results: Effectiveness of fissure sealants is supported by strong scientific evidence and also as a restorative material, 76% of the GDP agreed and 86.9% thought that it is difficult to justify the cost of sealants to parents. 62.2% valued that fissure sealants are used less than they should have been. Most of them had a positive attitude toward sealant application. Conclusion: Dental practitioners knowledge of pit and fissure sealant is high and attitude is also positive but when comes to practice it has been underutilized.
Keywords: Dental, dental sealants, oral, prevention and control
|How to cite this article:|
Mohammed IP, Jaleel BN, Amarah U, Hiremath S S, Manjunath C, Krishnamoorthy A. Knowledge, opinion, values, and practice of sealant use among dental practitioners in Bangalore city. J Indian Assoc Public Health Dent 2021;19:71-5
|How to cite this URL:|
Mohammed IP, Jaleel BN, Amarah U, Hiremath S S, Manjunath C, Krishnamoorthy A. Knowledge, opinion, values, and practice of sealant use among dental practitioners in Bangalore city. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Oct 22];19:71-5. Available from: https://www.jiaphd.org/text.asp?2021/19/1/71/312650
| Introduction|| |
For many years, it has been recognized that the occlusal pits and fissures of posterior teeth are highly susceptible to caries. Occlusal caries constitutes more than two-thirds of total caries in the permanent posterior teeth of Western children. Numerous techniques and methods have been advocated to prevent occlusal pit-and-fissures caries. Fluoride has been the material of choice for preventing smooth surface caries; however, it has been less effective in reducing pit-and-fissure caries.,, Recent Cochrane review has recommended sealants in preventing occlusal caries in children and adolescents. The American Dental Association emphasizes the use of dental sealants as an effective preventive method in controlling occlusal pit-and-fissure caries. According to Gift, out of 100 dental practitioners, only 15%–20% said that they use dental sealants in their practice. In the dental profession, a controversy exists about the effectiveness of and need for dental sealants. The dental profession has not used them to their greatest advantage., In general, the resistance of dentists to use sealants stemmed from several sources: Dentists' orientation toward restorations rather than prevention, distrust of the long-term benefits of sealant treatment, perceived economic factors, lack of confidence in caries risk assessment, and concern about inadvertently sealing over caries. Evidence-based clinical recommendations for the use of pit-and-fissure sealants by a panel of the American Dental Association's Council on Scientific Affairs recommend placing them in children and adolescents on early (noncavitated) carious lesions. Fissure sealant programs serve only to delay rather than prevent the need for restorative care, there is still a substantial benefit to be gained since it has been shown that the half-life of restorations is considerably greater if the child is older than 9 years when the restoration is placed.
There are more than 11 guidelines and systematic reviews that have recommended the use of pit and fissure sealants for at-risk populations to reduce occlusal caries. However, studies from the U. S., Greece, Sweden, and Scotland, Spain all indicate that sealants are underutilized. The theoretical frame for behavior change is an assessment of knowledge and attitudes affecting practice. However, neither theories of behavior change nor knowledge nor attitudes predict clinical practice. Instead, both indicate that values are better predictors.
Therefore, the aim of the present study was to examine knowledge combined with opinions, values, practice of sealant use among dental practitioners in Bangalore city.
| Materials and Methods|| |
A descriptive cross-sectional s urvey was conducted to assess the knowledge, opinion, value, and practice of sealant use among the active private dental practitioners in multispecialty clinics, single-specialty clinics, and corporate hospitals of Bangalore city for 3 months from July 2014 to September 2014. According to the registry of dental care facilities in Bangalore available at District Health Office, Bangalore Urban a total of 1100 registered dental clinics was present. Raosoft was used to generate sample size and power calculation (http://www.raosoft.com/samplesize.html). For a 5% margin of error, a 95% confidence level, a population of 20000, and a response distribution of 50%, the minimum recommended sample size was 312. Convenience sampling method was used utilized, to select multispecialty clinics, single-specialty clinics, and corporate hospitals. The private dental practitioners who declined to give the consent were excluded from the study and the only dentists who consented were included in the study. The study protocol was reviewed and approved by the Institutional Ethical Board. A self-administered 5-Point Likert scale questionnaire used in the study by Martin et al. was modified and given to the dentists who participated in the study. Test-retest validity was determined with 15 dentists retested at an interval of 1 week (Cronbach's alpha = 0.812). These participating dentists were not included in the main study. The data were collected in 2 months allowing the flexibility to accommodate any unforeseen circumstances. The questionnaire consisted of a total of 25 questions divided into knowledge (Q1-Q12), Value (Q13-Q17), opinion (Q18-Q21), and practice (Q22-Q25) domains. The study was done in the working hours of the dental clinics so as get the maximum response. Consequently, if the dental clinic was closed or dentists were not available then the clinic was revisited within a week. In the questionnaire form, the respondents were informed about the aim of the study as well as the fact that participation in the questionnaire survey was voluntary and anonymous. Statistical analysis was done using a computer with the aid of Statistical Package for Social Science (SPSS), version 21, USA (IBM). In the present study, descriptive statistics were used to summarize the variables. For each of the 25 survey items and for each of the four assessment domains (knowledge, opinions, values, and practice) domains (knowledge, opinions, values, and practice) mean percentage scores were calculated. Analysis of variance (ANOVA) has been used for comparison between three or more groups of study participants, Student's t-test (two-tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups. Reverse scoring for the questions was done to calculate each domain score. To examine the relative importance of each of the four domains of knowledge, opinion, value, and practice of the questionnaire, index scores were calculated for each domain of the questionnaire by taking the actual score and dividing by the total possible score for that domain possible score for that domain, allowing direct comparisons between the domains.
| Results|| |
When the General Dental Practitioners (GDP) were distributed according to the age group, 71 (22.8%) were belonging to 20–24 years, 102 (32.7%) were 25–29 years, 110 (35.3%) were 30–34 years, 13 (4.2%) were 35–39 years, 8 (2.6%) were belonging to 40–44 years, 8 (2.6%) were 45 and above years old, respectively. Among a total of 312 GDP, 124 (39.7%) were males and 188 (60.3%) were females. Among the 312 GDP, majority 151 (48.4%) were having 0–3 years' experience, 122 (39.1%) were having 4–10 years of experience, 39 (12.5%) were having more than or equal to 11 years of experience.
The mean ± standard deviation scores for the 12 (Q1-Q12) questions of knowledge domain individual questions ranged from 2.47 ± 1.06 to 4.58 ± 0.65 with an overall of 3.93 ± 0.45, for the value domain 12 (Q13-Q17) questions of individual questions ranged from 2.75 ± 1.19 to 3.74 ± 0.96 with an overall of 3.23 ± 0.53, opinion domain 12 (Q18-Q21) questions of the individual questions ranged from 3.00 ± 0.86 to 4.37 ± 0.69 with an overall of 3.83 ± 0.57 and for practice domain 12 (Q22-Q25) questions of the individual questions ranged from 2.76 ± 1.2 to 4.00 ± 0.70 with an overall of 3.40 ± 0.34, respectively.
Knowledge differed by years of experience, P = 0.018, opinion differed by years of experience P = 0.008, value differed by years of experience, P < 0.001. Similarly, practice about sealants differed by years of experience, P < 0.001, and all they had statistically significant differences. Post hoc analysis for the years of experience revealed that having more than or equal to 11 years of experience is significantly associated with increased value and 4–10 years' experience were having higher knowledge, opinion, and practice about sealant use [Table 1].
|Table 1: Mean knowledge, value, opinion, and practice scores among dental practitioners|
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Statistically significant negative correlations were found between knowledge and practice r = −0.113, P ≤ 0.045 and also value r = −0.541, P ≤ 0.001 showed a similar negative correlation with knowledge. Statistically significant positive correlations were found between value and opinion r = 0.26, P ≤ 0.001 also practice r = 0.39, P ≤ 0.001 showed similar results. Statistically significant correlations were found between opinion and practice r = 0.69, P ≤ 0.001 [Table 2].
|Table 2: Relationship between mean knowledge, values, opinions, and practice|
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[Figure 1] shows the mean percentage scores of 78.63%, 64.75%, 76.77%, and 68.79 for knowledge, value, opinion, and practice, respectively.
|Figure 1: The mean percentage scores of the knowledge, value, opinion, and practice domain|
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| Discussion|| |
A descriptive cross-sectional survey was conducted to assess the knowledge, opinion, value, and practice of sealant use among dental practitioners in Bangalore city. GDP in Bangalore City, have neutral to positive knowledge, opinion, values, and practice attitudes about sealants. These results are similar to one reported by Martin et al., Farsi et al., Lack of knowledge about sealants has frequently been cited as a possible deterrent to its adoption. However, in this study group, mean percentage knowledge score was 78.63% and also knowledge regarding the sealant used was positive, but still there was an underutilization of sealant suggesting other factors may be playing a key role in the practice behaviors. Aleksejuniene et al. in her extensive review listed the reasons for dentists low sealant use, they are dentists orientation toward restorations rather than prevention, distrust of the long-term benefits of sealant treatment, perceived economic factors, lack of confidence in caries risk assessment, and concern about inadvertently sealing over caries. The majority of the GDP (81.4%) agreed that the effectiveness of fissure sealants is supported by strong scientific evidence. Similar results are also reported by Martin et al. where 64.2% agreed with the Likert item. For restorative use of dental sealants, all of them agreed with the Likert item. These results are in contrast to one reported by Martin et al. where only 42% of them agreed with the Likert item. Hassall et al. reported that the treatment data indicated that only 59 of the 4,250 children received a sealant restoration during the study. Of the 44 dentists who claimed in the questionnaire to be using sealant restorations, only 28 had placed them in their selected patients. The author suggested that although positive attitudes to sealant restorations were expressed, also there were concerns that may be prejudicing usage. A recent survey by Tellez et al. of U. S. dentists found that <40% indicated they were following the ADA's evidence-based recommendations for sealing noncavitated carious lesions.
Gonzalez et al. reported that more frequent use of sealants was associated with having higher knowledge scores and having more favorable opinions about sealants. Michalaki et al. reported insufficient knowledge, leading to low usage rates.
The mean percentage scores for the value domain among GDP were 64.75%. Porter et al. reported that work at the Harvard Business School suggests that focusing on values may be the key driver for health improvement. He also reported that achieving high value for patients must become the overarching goal of health-care delivery, with value defined as the health outcomes achieved per dollar spent. This goal is what matters for patients and unites the interests of all actors in the system. If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health-care system increases. However, even though GDP had higher values it did not translate into the utilization of sealant in their clinical practice. Mean percentage scores for the Opinion domain among GDP 76.77%. In this study, majority of the respondents had an opinion that it is difficult to explain to patients what dental sealants are (86.9%) and also justify the cost of sealants to parents (86.9%). These might be one of the reasons for the underutilization of sealants in this study population. Selwitz et al. reported that a lack of public knowledge and belief about the efficacy of dental sealants also influences parental acceptance of sealants for their children. These results are also similar ones reported by Martin et al. Romberg et al., who reported that improving patient and practitioner opinion and knowledge about sealants should be undertaken. In a country like India, it is difficult to motivate patients towards preventive practices, where the majority of the patients are inclined toward pain relief and surgical treatment. Oulis et al. reported that expressed concerns such as “parents do not pay” or “unaware how to use them” or “other preventive measures like oral hygiene are sufficient to prevent caries” show that there is a serious lack of the appropriate knowledge between GDP in Greece, regarding sealant effectiveness. On the other hand, dentists are very important in educating parents on caries prevention issues and they can increase sealant use in the population. This occurs because parents are more inclined to accept advice from them on caries prevention since dentists are the most appropriate source of information on such issues. Also, the GDP has to take a step to explain the beneficial effects of sealant to patients if its use has to increase in the clinical practice.
The mean percentage scores for the practice domain among GDP were 68.79%. This is lower when compared to the knowledge mean percentage score. As most of the treatment is out of the pocket expenses in India, most of the patients do not opt for sealant therapy this might be one of the reasons for underutilization. In addition, in this study, majority of the respondents had an opinion that it is difficult to explain to patients what dental sealants are (86.9%) and also justify the cost of sealants to parents (86.9%). These might be one of the reasons for the underutilization of sealants in this study population. Selwitz et al. reported that a lack of public knowledge and belief about the efficacy of dental sealants also influences parental acceptance of sealants for their children. These results are also similar to those reported by Martin et al. Knowledge differed by years of experience (P = 0.018), Opinion differed by years of experience (P = 0.008), value differed by years of experience (P = 0.000). Similarly, practice about sealants differed by years of experience (P = 0.00), and all of them had statistically significant differences. These results are similar to the one reported by Martin et al., but in their study, only opinion and practice had a significant association. There were no significant differences found between KVOP and Gender. Respondents' gender and year of graduation were associated in some surveys with the level of sealants used. The issue of patient's acceptance and willingness to pay for sealants were the concerns of the respondents who were not using sealants. The reasons given for lack of usage are similar to those reported in the literature.
A common implicit model is a Knowledge-Attitudes-Behavior model. This assumes that a change in knowledge will produce a change in attitude, and these will, in turn, produce a change in behavior. Hence, value and opinion were measured in this study which showed a positive correlation with sealant use. These results are in contrast to one reported by Martin et al. He also reported that economics, not KVOP, maybe the practice drivers in Spain. Interestingly, Clarkson et al. examined the economic/education/values hypothesis. They found that only economics altered practice behavior by dentists. In this study, value and opinion had a positive correlation with the sealant practice. However, none of them had a positive impact on sealant usage. The limitations of the study are as it is a one-time measurement caution to be followed while interpreting the results. Hence, there should be a Paradigm Shift to Prevention, in clinical practice as well as dental education in India to bring change in the attitude of future dental professionals in India.
| Conclusions|| |
- Mean knowledge score, opinion score, value score, practice score of the GDP toward the use of sealants in the Bangalore City, was neutral to positive
- Despite increased knowledge and opinion, there was a lower utilization of sealant
- Experienced dentists had higher knowledge, opinion, and value, were more likely to use sealants.
I would acknowledge all the participants of the study for their time and support in completing this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Task Force on Community Preventive Services. Promoting oral health: Interventions for preventing dental caries, oral and pharyngeal cancers, and sport-related craniofacial injuries. MMWR 2001;50(RR21):1-13.
Backer DO. The relation between the fluoridation of water and dental caries experience. Int Dent J 1967;17:582-605.
Horowitz HS. Effect on dental caries of topically applied acidulated phosphate fluoride: Results after two years. J Am Dent Assoc 1969;87:568-72.
Houwink B, Backer DO, Kwant GW. A nine-year study of topical application with stannous fluoride in identical twins and the caries experience five years after ending the applications. Caries Res 1974;8:27-38.
Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Oral Health Group, editor. Cochrane Database of Systematic Reviews; 2017. Available from: http://doi.wiley.com/10.1002/14651858.CD001830.pub5
. [Last cited on 2021 Jan 02].
Frew RA. Pit and fissure sealants. Council on dental materials, instruments, and equipment. J Am Dent Assoc 1983;107:465.
Gift H. Motivation-technology transfer of pit and fissure sealants: In: Proceedings Conference on Pit and Fissure Sealants: Why their Limited Usage? Chicago: American Dental Association; 1981. p. 49.
Eden GT. Clinical evaluation of a pit and fissure sealant for young adults. J Prosthet Dent 1976;36:51-7.
Sarmadi R, Gahnberg L, Gabre P. Clinicians' preventive strategies for children and adolescents identified as at high risk of developing caries. Int J Paediatr Dent 2011;21:167-74.
ADA Council on Scientific Affairs. Use of Pit and Fissure Sealants: Evidence-based clinical recommendations. JADA 2008;139:257-68.
San Martin L, Castaño A, Bravo M, Tavares M, Niederman R, Ogunbodede EO. Dental sealant knowledge, opinion, values and practice of Spanish dentists. BMC Oral Health 2013;13:12.
Farsi NM. The effect of education upon dentists' knowledge and attitude toward fissure sealants. Odontostomatol Trop 1999;22:27-32.
Hicks MJ, Call RL, Flaitz CM. Colorado pit and fissure sealant survey: Attitudes toward and use of pit and fissure sealants by Colorado general dentists. J Colo Dent Assoc 1989;68:8, 10-5.
Aleksejuniene J, Brondani MA, Pattanaporn K, Brukiene V. Best practices for dental sealants in community service-learning. J Dent Educ 2010;74:951-60.
Hassall DC, Mellor AC. An investigation into sealant restoration usage in general dental practice in England. Br Dent J 2001;191:388-90.
Tellez M, Gray SL, Gray S, Lim S, Ismail AI. Sealants and dental caries: Dentists' perspectives on evidence-based recommendations. J Am Dent Assoc 2011;142:1033-40.
Gonzalez CD, Frazier PJ, Messer LB. Sealant use by general practitioners: A Minnesota survey. ASDC J Dent Child 1991;58:38-45.
Michalaki M, Sifakaki M, Oulis CJ, Lygidakis NA. Attitudes, knowledge and utilization of fissure sealants among Greek dentists: A national survey. Eur Arch Paediatr Dent 2010;11:287-93.
Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81.
Selwitz RH, Colley BJ, Rozier RG. Factors associated with parental acceptance of dental sealants. J Public Health Dent 1992;52:137-45.
Romberg E, Cohen LA, LaBelle AD. Importance of variables associated with practitioners' estimates of pit and fissure sealant use. J Public Health Dent 1988;48:138-46.
Oulis CJ, Berdouses ED, Mamai-Homata E, Polychronopoulou A. Prevalence of sealants in relation to dental caries on the permanent molars of 12 and 15-year-old Greek adolescents. A national pathfinder survey. BMC Public Health 2011;11:100.
Lang WP, Farghaly MM, Woolfolk MW, Ziemiecki TL, Faja BW. Educating dentists about fissure sealants: Effects on knowledge, attitudes, and use. J Public Health Dent 1991;51:164-9.
Eccles MP, Grimshaw JM, MacLennan G, Bonetti D, Glidewell L, Pitts NB, et al
. Explaining clinical behaviors using multiple theoretical models. Implement Sci 2012;7:99.
[Table 1], [Table 2]