|Year : 2020 | Volume
| Issue : 9 | Page : 4761-4768
Knowledge of oral health among family medicine physicians in Riyadh, Saudi Arabia 2020
Buthainah Alshathri, Nourah Aljasser, Mostafa Kofi
Department of Family and Community Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
|Date of Submission||18-May-2020|
|Date of Decision||19-Jun-2020|
|Date of Acceptance||23-Jun-2020|
|Date of Web Publication||30-Sep-2020|
Dr. Buthainah Alshathri
Al Amir Mansur Ibn Abdul Aziz, Al Wizarat˛ Al Wizarat, Riyadh 12624
Source of Support: None, Conflict of Interest: None
Background: Preventive oral health care (OHC) is an important part of preventive health care and needs to be started early in life. Family physicians are in a position where they can help to initiate preventive OHC. From previous literature, oral health has an impact on the general health and quality of life of individuals with a large burden on the health care system. In addition, pediatricians and family physicians lack knowledge in oral health and can be unwilling to participate in preventive OHC. We aim to increase family physicians' knowledge of oral health. Objectives: This study aimed to measure the level of knowledge about oral health and identify some of its determinants among family physicians working in Riyadh, Saudi Arabia. Methods: This is a cross-sectional study that included 187 family physicians to measure the knowledge of family doctors about oral health using a self-administered questionnaire. Results: The total mean score was 119.28 ± 11.26 out of 175, indicating a poor level of knowledge level about oral health. Conclusion: Family physicians in Riyadh, Saudi Arabia lack knowledge of oral health. These findings make it necessary to include oral health topics during residency and continuing medical education programs.
Keywords: Family physicians, knowledge and awareness, oral health, physicians, primary care physicians
|How to cite this article:|
Alshathri B, Aljasser N, Kofi M. Knowledge of oral health among family medicine physicians in Riyadh, Saudi Arabia 2020. J Family Med Prim Care 2020;9:4761-8
|How to cite this URL:|
Alshathri B, Aljasser N, Kofi M. Knowledge of oral health among family medicine physicians in Riyadh, Saudi Arabia 2020. J Family Med Prim Care [serial online] 2020 [cited 2020 Oct 20];9:4761-8. Available from: https://www.jfmpc.com/text.asp?2020/9/9/4761/296372
| Background|| |
The World Health Organization (WHO) defines health as “a complete state of physical, mental, and social well-being and not just the absence of disease” (WHO, 1948). Oral health plays an important role in the general health of individuals. Many systemic diseases have been connected to oral disease, and the systemic diseases have oral manifestations., Kane mentioned in his study that, “Atherosclerotic vascular disease, pulmonary disease, diabetes, and pregnancy-related complications are the major conditions that effect a large percentage of the population and have been well-studied for their relationship to oral health.” Oral health and tooth loss can affect the quality of life of individuals., Oral hygiene is poor and introduced late in the life of Saudis., Parents' oral health status can affect their children's' risk of caries. Dental caries are common among Saudi children. A systemic study on the prevalence of caries among Saudi children concluded, “The national prevalence is estimated to be 80% in the primary dentition,” and “it is estimated to be 70% for children's permanent dentition.” A good oral health status can decrease costs on the health service. In the reviewed literature, the global direct cost because of dental disease was estimated at US $298 billion and indirect costs at US $144 billion yearly. Family physicians being the connection of the community with the health care system could educate their patients regarding oral health. Low level of knowledge was mentioned in previous literature by physicians as a barrier to providing oral health care (OHC) to their patients.
In efforts to improve health care and decrease the large burden on the health care system because of oral disease, this study aimed to increase the awareness of family physicians about the importance of oral health and its impact on patients' overall health by implementing educational programs about oral health. We hope this paper shows the importance of oral health and general well-being of individuals to family physicians and to give oral health a place in the postgraduate and continuous medical education.
The objective of this study was to measure the level of knowledge of family physicians working in Riyadh, Saudi Arabia about oral health in terms of the effect of oral health on systemic health, pediatric dentistry, and general dentistry and to identify determinants of oral health knowledge among primary care physicians.
| Methods|| |
This is a cross-sectional study conducted on family physicians working in primary care centers of three large hospitals in Riyadh, Saudi Arabia. We randomly selected and distributed a self-administered questionnaire to 241 family physicians who were working in the primary care centers. Due to the lack of time and different schedules of physicians, the sampling method was convenient. The questionnaire was developed based on previous literature and presented to three consultants of family medicine for validation of the contents, and a pilot study was done on 18 family physicians to evaluate feasibility. The questionnaire consisted of sociodemographic data (including age, gender, nationality, position, years of experience, and whether the participants had received previous training on oral health) and 3-point Likert scale questions on oral health and systemic health with 10 items, pediatric dental questions with 11 items, and general dental questions with 14 items. Participants were asked to answer with “Strongly Agree,” “Agree,” “I Don't Know,” “Disagree,” or “Strongly Disagree.” One hundred and eighty-seven questionnaires were returned to a response rate of 77%. After excluding the uncompleted questionnaires, 167 questionnaires were included in the study.
Data were analyzed using the Statistical Package for the Social Studies software (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. t-test and one-way analysis of variance were used for continuous variables. Cronbach's alpha was used to assess the reliability and internal consistency of the items in the questionnaire. Univariate and multivariate logistic regressions were used to assess the risk factors for poor knowledge.
Approval letter for the study was obtained from Institutional review board (IRB) committee at the Prince Sultan Military Medical City no. HP-01-R079. Participants' consent was taken at the beginning of each questionnaire. The privacy of participants was maintained and no effort was made to identify participants. Collected information is kept confidential, and it was ensured that no harm is done to any study participant. The gathered information was only used for this study and no other purpose. Departmental heads' approval was taken before distributing the questionnaires.
| Results|| |
This cross-sectional survey study was conducted to assess the level of knowledge of family physicians working in Riyadh, Saudi Arabia about oral health and to identify determinants of oral health knowledge among family physicians. Cronbach's alpha was calculated to assess the reliability of the questionnaire, and it scored at 0.819 for overall items, which reflects good reliability and internal consistency of the items in the questionnaire.
A total of 167 family physicians participated in this study. More than half (55.09%) of the participants were female, the vast majority (90.42%) were Saudi, and the highest number of participants (80.24%) were in the age group of 25 to 34 years. Most (79.64%) of the study participants were residents, and 76.05% had over 5 years of experience. The results of this study revealed that only 7.19% of the family physicians received training on oral health, whereas the vast majority (92.81%) did not. Data are shown in [Table 1].
Frequencies of physicians' answers and the mean score of answers for the knowledge of oral health are shown in [Table 2] and [Table 3]. Generally, the total mean score of the whole questionnaire used in this study was 119.28 ± 11.26 out of 175, indicating a poor knowledge level of oral health. For the first domain of oral health and systemic health, the overall mean score was 32.66 ± 3.73 out of 50, indicating a poor knowledge of the association of oral health with systemic health. When looking at this domain items, the results showed that most of the family physicians in this study had poor knowledge about the correlation between gingival disease and systemic disease and dental caries and systemic disease, as most of them incorrectly agreed that they are correlated, at 88.6%, and 85.6%, with mean ± SD scores of 1.72 ± 0.69 and 1.71 ± 0.88, respectively. On the other hand, they were highly knowledgeable about the correlation between infective endocarditis and oral infection and diabetes and oral infection, at 91.0%, and 88%, with mean ± SD scores of 4.32 ± 0.75) and 4.31 ± 0.81, respectively. In addition, 84.4% of the participants knew that there is a correlation between periodontal disease and systemic disease. The results also showed that more than half of the participants do not know that there is a relation between low birth weight and oral infection and preterm labor and oral infection (53.3% and 59.9%, respectively). It was reported by 77% of the participants that they did not know about the correlation between bacterial pneumonia and oral infection.
|Table 2: Frequencies of physicians' answers for the Knowledge of Oral Health (n=167)|
Click here to view
For the pediatric dental health domain, 76.6% of the physicians knew that the age for first primary tooth eruption is between 6 and 12 months of age and 71.3% of the physicians knew that thumb sucking is a risk factor for dentoalveolar malformation in children past the age of 3 years. Three quarters (75.4%) of the physicians correctly “Disagree” that sleeping with bottle protects against dental caries, whereas 10.2% agreed on this. The highest percentage (43.7%, each) of the respondents did not know the right time for the first visit to a dentist and for starting fluoride supplements. More than half (50.9%) of the family physicians did not know that white spots on teeth or lines can be the first sign of decay, while 35.3% incorrectly disagreed with it, only 13.8% correctly agreed to that point. Forty-seven (47.3%) of participants agreed that frequency of sugar intake is more important than amount in causing tooth decay, 44.9% said “don't know”, and 7.8% disagreed.. In general, the total score of this domain was 39.49 ± 4.50 out of 55, indicating a good level of knowledge about pediatric dental health.
The results of this study revealed that family physicians have a poor level of knowledge about general dental health, as the total mean score of this domain was 47.14 ± 5.75 out of 70. The highest level of knowledge in this domain was for smoking, aging, and genetic factors as risk factors for periodontal disease by 96.4%, 70.1%, and 68.9% of the physicians, respectively. For the item “If needed, pregnant women referred to dental care at the second trimester,” the majority of the physicians' responses were either “Agree” and “Don't know,” whereas only 9.6% gave the right answer “Disagree”. Antidepressants, antihypertensive, and analgesic drugs can increase the risk of dental caries; however, almost three quarters (75.4%, 74.3%, and 74.3%, respectively) of physicians answered with a “Don't know.”
Knowledge scores for the three domains were calculated by physicians' characteristics and the results are shown in [Table 4]. Overall, female gender showed a higher mean knowledge score at 121.38 (±11.09) compared to males at 116.71 (±11.00) and was highly statistically significant (P 0.007).. There was a statistically significant difference in the oral health knowledge score by age, where the highest knowledge score was for the age group of 55 to 64 years at 141.33 ± 8.08. Non-Saudi physicians showed a statistically significant higher oral health knowledge scores at 130.13 ± 11.87, compared with Saudi ones at 118.13 ± 10.60, with P < 0.001. For position and oral health knowledge, registrars scored the highest knowledge at 131.08 ± 15.69, with a significant difference compared with other positions at P = 0.001. There was a statistically significant correlation between experience in the medical field and oral health knowledge, where the knowledge score was found to increase by increasing the experience years, reaching its highest with those having experience of 16 to 20 years at 130.00 ± 13.30. However, it decreased again with physicians having experience lesser than 20 years. Family physicians who received training on oral health showed a nonsignificant higher total mean knowledge score compared with those who did not receive training at 124.17 ± 9.32 versus 118.90 ± 11.33, with P = 0.119. When looking at each of the studied domains separately, it is noted that the knowledge score in both pediatric dental health and general dental health differed significantly by gender, age, nationality, years of experience, and study. In contrast, oral health and systemic health score did not show a significant difference with any of these factors.
|Table 4: Knowledge scores (mean, SD) in the three domains among the physicians (n =) by their characteristics|
Click here to view
Univariate logistic regression analysis was done to assess the factor associated factors with a low level of oral health knowledge, and the results are shown in [Table 5]. Men showed more than two times the risk of poor knowledge with OR 2.42 (95 C1% 1.29–4.52; P = 0.006). Physicians aged <35 years having significantly more than five times (OR =5.79) increased risk of low oral health knowledge (95% CI 2.22-15.07 and p<0.001). The Saudi nationality was a risk of low oral health knowledge with OR 9.02 (95% CI 1.98-41.06, and P 0.004).. In addition, resident position and experience of more than 5 years were significant risk factors for low oral health knowledge, as OR was 4.75 and 5.48, respectively, and P < 0.05 in both cases. However, when multivariate regression analysis was done, the male gender was the only factor that remained a statistically significant risk factor for low oral health knowledge, as shown in [Table 6].
|Table 5: Univariate logistic regression for associated factors with low knowledge of oral health|
Click here to view
|Table 6: Multivariate logistic regression for associated factors with low knowledge of 0ral health|
Click here to view
| Discussion|| |
Primary care providers, particularly family physicians, might have a profound impact on the oral health of their patients through integrating oral health in their practices, which can effectively address patients' oral health needs. This study was conducted to assess the knowledge of family physicians regarding oral health and to shed light on areas in which they need to improve their knowledge. We tried to collect important data regarding systemic health and oral health, pediatric dental health, and general dental health from the participating physicians. Overall, the results of this study showed a substantial lack of knowledge among family physicians regarding oral health. Such a finding is in line with a recently published similar study from India and other local, national, and international studies.,,,,,,, This lack of knowledge may act as a barrier to physicians' OHC delivery.
Training is critical for preparing physicians to take on new and expanded roles in OHC. In addition, it provides an excellent basis for developing their understanding of dental health. Usually, most young children are not examined by a dentist till they reach the age of 3 years; however, within the first year of their life, they visit primary care providers, including physicians, many times for health screenings. If physicians are sufficiently knowledgeable about OHC, they can provide consultation to the parents regarding feeding practices, oral home care (brushing/flossing), and fluorides. Furthermore, they could diagnose a carious lesion in its early stage and refer the child to a dentist for preventive procedures or early treatment, if necessary. As per the literature, some of the US health care centers provide oral health content during training sessions for their primary care providers and physicians to embrace OHC as an integral part of primary care. Unfortunately, in this study, 92.81% of the participants did not undergo training in oral health, indicating a lack of OHC training and, consequently, a low level of knowledge.
Despite the well-established relationship between oral health and systemic/general health,,, family physicians who participated in this study showed a poor level of knowledge in terms of oral and systemic/general health. Kane reported that atherosclerotic vascular disease, diabetes, pulmonary disease, and pregnancy-related complications are common to major conditions and have been well-studied for their relationship to oral health. However, it is worthy to mention here that although many of the studies on oral disease have not shown a statistically significant impact on these systemic conditions, neither profession will deny that maximizing a patient's health is advantageous.
The pediatric dental health domain showed the highest knowledge score in this study. In contrast to this finding, Rabiei, et al. reported that the knowledge score was significantly lower in the pediatric domain than in the dental and medical domains. In addition, the findings of this study are dissimilar to those in other investigations regarding physicians' knowledge about early childhood caries and infant oral health. The initial carious lesions are the so-called white spot lesions, and to diagnose the earliest stages of enamel demineralization, accurate and reliable detection of such lesions is very important. In this study, most of the participants either did not know this or disagreed on it. In accordance with a previous local study, this study showed that most of the family physicians were knowledgeable regarding the eruption age of the first primary tooth. In addition, most of them were aware of the effect of bottle night feeding on children's teeth, and this is similar to the findings reported by Indira, et al. In Patna, India, a study published in 2017 showed that both pediatricians and family physicians were less aware of the first dental visit, including early childhood caries.
It has been reported in the literature that periodontal disease can lead to adverse pregnancy outcomes., Therefore, physicians are expected to have a thorough knowledge of the impact of oral health on pregnancy and when to refer them to a dentist. However, in our study, only a few participants were aware of this fact. Similar findings were observed in previous studies conducted elsewhere on physicians and health care providers.,
Women showed a significantly higher knowledge score than men. The results of this study are in line with the other studies such as those by Schwarz and Al-Omari and Hamasha, in which women showed significantly higher oral health knowledge compared with men.
Based on the current study results, the overall level of knowledge was poor. The highest score was in the domain of pediatric dental health. Highest level of knowledge was among non-Saudi participants, females, older age groups and individuals with more years of experience, but the level falls again above 20 years of experience. Health care authorities should seek the reasons for the low training rate of family physicians on OHC, which might include the lack of training programs. Education and clinical training about the basic information for the maintenance of oral health should be included in the medical education and training curriculum. In addition, continuous education and training programs like web-based or distance training, in-service training, workshops, and seminars should be considered.
This was a cross-sectional study; therefore, we could not establish causality. A longitudinal study is needed to understand the possible determinants of OHC knowledge in different settings. The sample size was small and the majority of the participants were residents; therefore, the results cannot be generalized to cover all family physicians in Saudi Arabia. Due to a lack of time and resources, we could not assess the practices of oral health among family physicians.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Constitution of the World Health Organization, Signed on July 22, 1946, in New York City. International Organization. 1947;1(1):225-239.
Kane SF. The effects of oral health on systemic health. Gen Dent 2017;65:30-4.
Kim J, Amar S. Periodontal disease and systemic conditions: a bidirectional relationship. Odontology. 2006;94(1):10-21.
Gerritsen A, Allen P, Witter D, Bronkhorst E, Creugers N. Tooth loss and oral health-related quality of life: A systematic review and meta-analysis. Health Qual Life Outcomes 2010;8:126.
Al-Otaibi M, Angmar-Månsson B. Oral hygiene habits and oral health awareness among urban Saudi Arabians. Oral Health Prev Dent 2004;2:389-96.
Al-Qahtani S, Razak P, Khan S. Knowledge and practice of preventive measures for oral health care among male intermediate schoolchildren in Abha, Saudi Arabia. Int J Environ Res Public Health 2020;17:703.
Tinanoff N, Reisine S. Update on early childhood caries since the Surgeon General's Report. Acad Pediatr 2009;9:396-403.
Khan SQ, Khan NB, Arrejaie AS. Dental caries. A meta-analysis on a Saudi population. Saudi Med J 2013;34:744-9.
Al Agili D. A systematic review of population-based dental caries studies among children in Saudi Arabia. The Saudi Dent J 2013;25:3-11.
Listl S, Galloway J, Mossey P, Marcenes W. Global economic impact of dental diseases. J Dent Res 2015;94:1355-61.
Poudel P, Griffiths R, Wong V, Arora A, Flack J, Khoo C, et al
. Perceptions and practices of general practitioners on providing oral health care to people with diabetes-A qualitative study. BMC Fam Pract 2020;21:34.
Gambhir RS, Batth JS, Arora G, Anand S, Bhardwaj A, Kaur H. Family physicians' knowledge and awareness regarding oral health: A survey. J Educ Health Promot 2019;8:45.
Rabiei S, Mohebbi SZ, Patja K, Virtanen JI. Physicians' knowledge of and adherence to improving oral health. BMC Public Health 2012;12:855.
Al-Hussyeen A, Al-Sadhan S, Al-Dhalaan R, Al-Ghanim B. Pediatricians' knowledge and practices towards children's preventive oral health care in Saudi Arabia. Egypt Dent J 2003;49:827-34.
Sabbagh HJ, El-Kateb M, Al Nowaiser A, Hanno AG, Alamoudi NH. Assessment of pediatricians' dental knowledge, attitude and behaviour in Jaddah, Saudi Arabia. J Clin Pediatr Dent 2011;35:371-6.
Prakash P, Lawrence HP, Harvey B, Maclsaac WJ, Limeback H, Leake JL. Early childhood caries and infant oral health: Pediatricians' knowledge, practices and training. Paediatr Child Health 2006;11:151-7.
Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: A national survey. Pediatrics 2000;106:e84.
Krol DM. Educating pediatricians on children's oral health: Past, present and future. Pediatrics 2004;113:e487-92.
Sanchez OM, Childers NK, Fox L, Bradley E. Physicians' views on pediatric preventive dental care. Pediatr Dent 1997;19:377-83.
Yimenu D, Adelo E, Siraj E, Kassie T, Hammeso W, Demeke C, et al
. Health professionals oral health knowledge and practice: Unleashing the hidden challenges. J Multidiscip Healthc 2020;13:459-69.
Al-Habashneh R, Aljundi SH, Alwaeli HA. Survey of medical doctors' attitudes and knowledge of the association between oral health and pregnancy outcomes. Int J Dent Hyg 2008;6:214-20.
Mouradian WE, Wehr E, Crall JJ. Disparities in children's oral health and access to dental care. JAMA 2000;284:2625-31.
Maxey HL, Norwood CW, Weaver DL. Primary care physician roles in health centers with oral health care units. J Am Board Fam Med 2017;30:491-504.
Bayraktar G, Kurtulus I, Kazancioglu R, Bayramgurler I, Cintan S, Bural C, et al
. Oral health and inflammation in patients with end-stage renal failure. Perit Dial Int 2009;29:472-9.
Lankarani KB, Sivandzadeh GR, Hassanpour S. Oral manifestation in inflammatory bowel disease: A review. World J Gastroenterol 2013;19:8571-9.
Somma F, Castagnola R, Bollino D, Marigo L. Oral inflammatory process and general health. Part 1: The focal infection and the oral inflammatory lesion. Eur Rev Med Pharmacol Sci 2010;14:1085-95.
Roopa KB, Pathak S, Poornima P, Neena IE. White spot lesions: A literature review. J Pediatr Dent 2015;3:1-7. [Full text]
Alshunaiber R, Alzaid H, Meaigel S, Aldeeri A, Adlan A. Early childhood caries and infant's oral health; pediatricians' and family physicians' practice, knowledge and attitude in Riyadh city, Saudi Arabia. Saudi Dent J 2019;31(Suppl):S96-105.
Indira M, Dhull KS, Nandlal B. Knowledge, attitude and practice toward infant oral health care among the pediatricians of Mysore: A Questionnaire Survey. Int J Clin Pediatr Dent 2015;8:211-4.
Anand A, Sharma S, Prajapati VK, Tanwar AS. Knowledge and attitude of pediatricians and family physicians regarding pediatric dentistry in Patna 2017;5:4.
Tettamanti L, Lauritano D, Nardone M, Gargari M, Silvestre-Rangil J, Gavoglio P, et al
. Pregnancy and periodontal disease: Does exist a two-way relationship? Oral Implantol (Rome) 2017;10:112-8.
Shenoy RP, Nayak DG, Sequeira PS. Periodontal disease as a risk factor in pre-term low birth weight--an assessment of gynecologists' knowledge: A pilot study. Indian J Dent Res 2009;20:13-6.
] [Full text]
Schwarz E, Lo EC. Dental health knowledge and attitudes among the middle-aged and the elderly in Hong Kong. Community Dent Oral Epidemiol 1994;22(5 Pt 2):358-63.
Al-Omari QD, Hamasha AA-H. Gender-specific oral health attitudes and behavior among dental students in Jordan. J Contemp Dent Pract 2005;6:107-14.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]