Knowledge, Attitude and Practices in Treating Children with Special Healthcare Needs among Dental Practitioners in Mumbai Metropolitan Region: A Questionnaire-based Survey
Correspondence Address :
Jasmin J Winnier,
D.Y Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India.
Introduction: Dentistry for children with Special Healthcare Needs (SHCN) is challenging and it is essential to understand the barriers faced by dentists in managing such patients.
Aim: The aim of this survey was to assess the knowledge, attitude and practice of dental practitioners in Mumbai Metropolitan Region (MMR) in treating children with Special Healthcare Needs (CSHCN).
Materials and Methods: An observational, cross-sectional Questionnaire-based study was conducted in Mumbai Metropolitan Region (MMR) from January 2021 to August 2021. A 19-item questionnaire was sent to 1624 dentists through email and/ or whatsapp. The age, gender, years of clinical practice, the type of special children encountered, the behaviour management modalities and treatment done for these children were recorded.Data collected was entered into the software International Business Management (IBM) Statistical Package for Social Sciences (SPSS) statistics version 20.0 and analysed. Microsoft word and excel (year 2019) were used to generate tables.
Results: Of the 1624 surveys sent, 650 responses were received making it to 40% response rate. Majority of respondents 67% (n=433) were general dental practitioners and 64% (n=416) had their own private practice. Only 39% (n=251) dentists had treated CSHCN in their practice. The most commonly encountered disability was mental retardation and cerebral palsy 23% (n=151). Amongst the clinicians referring the case, most of them, 148 (59%) preferred to refer to paediatric dentists. Regarding the method of management, 78% (n=197) of respondents were confident in treating special children with non pharmacological behaviour management methods and 58% (n=146) were confident with pharmacological methods. The frequently performed treatment procedures were restorative and preventive methods. A total 61% (n=399) of respondents had not encountered CSHCN. Among them, 65% (n=261) felt they had inadequate training in their curriculum, 59% (n=157) wished to treat such patients in future and 56% (n=223) were interested in continuing dental education programmes on the same.
Conclusion: Majority of the dentists had treated children with mental retardation, cerebral palsy and physical disabilities than emotional disabilities. Non pharmacological behaviour management methods were preferred, and preventive and restorative procedures were frequently preformed. Most of the dentists in the present study reported themselves to lack knowledge in treating children with SHCN.
Awareness, Dental education, Oral health, Paediatric
The World Health Organisation (WHO) in 2020 has stated that around 15% of the global population, live with some form of disability (1). The American Academy of Paediatric Dentistry (AAPD) in year 2020, defined special healthcare needs as any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs. The condition may cause limitations in performing daily activities. It may be congenital, developmental, or acquired due to disease, trauma, or environmental cause (2).
Healthcare for children with special needs requires awareness, expertise, adaptation and additional measures beyond what are considered routine (3). Many general dentists are reluctant or not prepared to treat children with special needs due to the complexity of their medical conditions, patient behaviour, or inadequate training and experience (4),(5). Literature search has revealed that dentists have reported that treatment for children with special needs is stressful and too challenging to treat (6). Casamassimo PS et al., in year 2004,reported that only 10% of dentists examined children with special healthcare needs (CSHCN) (5).
Few studies have evaluated the quality of education provided in the dental schools for treating patient with special needs. A study conducted in Malaysian and Australian dental Schools, reported that dentists received inadequate undergraduate training in treating individuals with SHCN (7). Similar results were reported in another study on members of the Michigan Dental Association (6). Previous research has also suggested that better quality of education had an impact in increased possibility of treating patients with SHCN (5),(6),8]. In India there is limited literature on the attitude and willingness of dentists towards the treating children with special needs (9),(10).
Previous research conducted to investigate the knowledge, attitude, and practices of dental practitioners concluded that majority of the dentists who participated had only partial knowledge and insufficient training to effectively manage and treat CSHCN (9).Another pilot study reported that inadequate training was the primary barrier for treatment of children with SHCN (10).Therefore, the purpose of this study was to evaluate Knowledge, Attitude and Practice in treating children with Special Healthcare Needs (SHCN) among Dental Practitioners in MMR.
This observational, cross-sectional questionnaire-based study was conducted in the Department of Paediatric and Preventive Dentistry, D.Y.Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India, between January 2021 to August 2021. The study was approved by the Institutional Review Board (No – IREB/2021/PEDO/07).
Inclusion criteria: All dental professionals registered in the Indian Dental Association database from Mumbai Metropolitan Region were included in the study.
Exclusion criteria: Undergraduates, interns and dental professionals who declined to participate in the study were excluded.
A questionnaire was formulated based on previous studies by Dao LP et al., Casamassimo PS et al., which was modified to suit the current study (4),(5). It was prepared using google forms in English consisting of 19-items. The reliability and validity of the questionnaire was confirmed using a pilot study. The form was given to 10 Paediatric Dentists and 10 General Practitioners/ Dental Specialist other than Paediatric Dentists. The same questionnaire was given to same 20 dentists after one month and was reviewed for content validity which showed no requirement of modification in the questionnaire. Cronbach’s alpha statistic were used to construct validity and reliability obtaining a value of 0.8.
The questionnaire had 19 items and was divided in three sections:
First section: included the demographic data: age of the dentist, gender, field of specialty, year of graduation, type of practice, years of clinical experience and the types of disability encountered during practice.
Second section: assessed the knowledge and attitude of the dentist. The clinician’s ability to identify the condition, the type of treatment provided for children with special healthcare needs, the preferred method to carry out the treatment, if referral was required who did they refer to, the confidence of practitioner in treating CSHCN with pharmacological and non pharmacological methods and the barriers faced were evaluated in this section.
Third section: Included questions regarding the dentist’s interest to treat the patient with SHCN in future, how well they were educated in their undergraduate and postgraduate course and if they were interested in continuing dental education for treating patients with SHCN.
The number of dentists practicing in Mumbai Metropolitan Region (MMR) were obtained from the Indian Dental Association database. (https://www.ida.org.in/Directories/DentistsDirectory) The database showed that there are 2,825 dentists practicing in the MMR region.Among the registered dentists, contact details could be obtained of 1624 dentists who received the questionnaire via email or whatsapp. A follow-up reminder was sent after a week to those who did not initially responded.
Data collected was entered into the software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA) and analysed (IBM Corporation, Armonk, NY, USA). Descriptive and inferential statistical analyses was carried out in the present study. Microsoft word and Excel (year 2019) were used to generate tables.
Out of 1624 dentists, 650 dentists responded to the questionnaire giving a response rate of 40%. The study population comprised of 650 dentists. Majority of the respondents were between 24-35 years of age with the mean of 29.5±4.6 years. Responses from females were higher 67.5% (n=439) compared to males 32.5% (n=211). Responders from recent graduates from 2016-2021 was higher at 77.9% (n=507) (Table/Fig 1).
Majority of the respondents had clinical experience of 1-5 years which was 58.5% (n=380) (Table/Fig 2).
The mean distribution of participants according to different specialties are represented in (Table/Fig 3). The type of practice of respondents is shown in (Table/Fig 4).
Among the dentists who responded to the questionnaire, 39% (n=251) of practitioners treated children with SHCN while 61% (n=399) did not treat children with SHCN. Among the ones who encountered CSHCN (39%, n=251), 64.9% (n=162) could identify the syndrome while 35.46% (n=89) were unable to do so.The most commonly encountered disability was mental retardation and cerebral palsy followed by other conditions (Table/Fig 5). It was also observed that, if the practitioner preferred to refer, 58.96% (n=148) referred to a paediatric dentist (Table/Fig 6). Non pharmacological method of management was the most preferred method among the respondents 78.48% (n=197) (Table/Fig 7). The most commonly carried out treatment modalities for CSHCN is given in (Table/Fig 8). The commonly encountered barriers in treating such patients is shown in (Table/Fig 9). Amongst those who encountered the CSHCN, primary barrier encountered to manage CSCHN was lack of knowledge 86 (34.26%).
Among the 61% (n=399) percentage of the respondents who did not treat CSHCN, it was seen that 65.41% (n=261) reported that their undergraduate or postgraduate education was inadequate to manage CSHCN. A total of 58.64% (n=234) wished to provide treatment for special children in the future and 55.88% (n=223) were interested in continuing dental education regarding the same (Table/Fig 10).
This study gathered information regarding knowledge, attitude and practice in treating children with Special Healthcare Needs (SHCN) among Dental Practitioners in MMR, India. The response rate seen in the present study was 40%.Previous studies conducted by Salama FS et al., elicited a response rate of 46 % and 41% respectively (4),(11). Amongst the responses received in the present study, 67% were from general dental practitioners followed by other specialities. This is higher than the 52% of responses obtained from general dental practitioners in a study by Loeppky WP and Sigal MJ (12). In the present study, it was noted that 64% of the respondents were private practitioners. This was similar to the study by Salama FS et al., where 67% were solo practitioners (11).
In the current study, an estimated 39% of participants treated CSHCN. Previous studies conducted among members of Americans with Disabilities Act (ADA) and in Bulgaria reported that and 10% and 28.7% of practitioners respectively treated children with special healthcare needs (5),(13).Contrary to this, Halawany HS et al., in year 2011 in Riyadh, Saudi Arabia reported that 85% of the respondents treated CSCHN. They credited this finding to their educational programs which strengthened the resolve those practitioners who already serve these individuals with overwhelming needs (14). Similar results were seen by a study conducted in Oredugba FA and Sanu OO among Nigerian dentists, where 80% of the respondents treated CSCHN (15). Considering the data from countries like Riyadh and Nigeria, it appears that’s dentists from MMR have a higher degree of hesitancy in treating CSHCN.
The most commonly encountered disability by the respondents in the current study were conditions like mental retardation and cerebral palsy followed by physical disabilities. These were perhaps the most easily distinguishable conditions and 45% of dentists encountered such patients. The least commonly encountered disability was emotionally challenged which included child abuse and neglect. The reason could be that, in many cases, it is quite difficult to recognise such conditions without thorough case history. A Nigerian study reported that the most commonly encountered disability by dentists was physical or motor disabilities which was about 39.3% and a Malaysian study reported it to be 58% (5),(16). It was also observed that if the practitioner preferred to refer, 23% referred to paediatric dentist and only 3% did not carry out any referral.
The 78% of the respondents who treated CSHCN in the present study preferred to treat them using non pharmacological modality.The survey by Rajan S et.al; in year 2019, reported that non pharmacological management was performed by 44.5% of practitioners (9). The use of non pharmacological method does not require additional training and thereby is commonly preferred. In the current study, it was seen that 41% of the practitioners were not confident at all to treat CSHCN using pharmacological means. The use of sedation and general anaesthesia, carries some risks which may not be easily managed without adequate training (15). It was seen that preventive and restorative treatment were most commonly carried out procedures (30% each). These were seen more in the present study population, probably because they are the easier and effective procedures. This was followed by extraction and endodontic treatment in the present study. The least carried out procedures were prosthodontic and orthodontic treatment, may be since it requires a certain degree of patient compliance. In contrast, studies by Smith G et al., (year 2004), Doichinova L and Peneva M (year 2014), Bindal P et al., (year 2015) have reported that emergency dental aid was carried out by 70%, 58% and 30% of clinicians respectively (13),(16), (17).
The majority of the practitioners mentioned that the primary barrier encountered to manage CSHCN was lack of knowledge (34%) followed by the caretaker not willing to proceed with the recommended treatment. Similar findings were reported by Bindal P et al., (2015) where 60.8% of the dentists found it difficult to treat CSHCN due to lack of training (16). Patient’s behaviour and insufficient training (40%) were the major barriers found in the survey by Salama FS et al., (11).
(Table/Fig 11) mentions the key Details the existing literature available on dentists’ willingness to treat children with SHCN (4),(5),(6),(9),(12),(13),(14),(15),(16). In the present study, 61% of practitioners did not encounter CSHCN. Amongst these practitioners, 65% responded that their undergraduate and post-graduate training was inadequate for management of CSHCN. In the current study it was seen that 59% wished to treat children in the future and 56% of the dentist were interested in continuing dental education, courses/programs in the field of special health needs. Declerck D in 2006 stated that dentists who had undergone training for treating specially challenged individuals perceived few barriers (18). Therefore, additional training could provide opportunity to the practitioners to have rapport with such patient’s parents and to confront their fears and anxieties about treating them in the future (19).
In the present study, the majority of respondents had graduated in the year 2018, having a clinical experience of 1-5 years. This could be a reason why increased number of respondents did not encounter children with special healthcare needs. Stratification of the response by years of experience would give more clarity on willingness of the dentist to treat children with SHCN.
Majority of the dentists who encountered CSHCN (39%) reported to have treated children with mental retardation, cerebral palsy and physical disabilities more than emotional disabilities. Most of the dentists (78%) treated CSHCN using non pharmacological behaviour management methods and primarily performed preventive and restorative procedures. It was also seen that majority of the dentists reported that they lacked knowledge in treating children with SHCN.
Date of Submission: Jan 19, 2022
Date of Peer Review: Feb 18, 2022
Date of Acceptance: Mar 21, 2022
Date of Publishing: Jun 01, 2022
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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