ABSTRACT
Background
It is desirable for doctors to conduct caries risk assessment (CRA) and evaluate the child's need for dental referral as medical visits in the first year of life surpass dental visits.
Aim
This study aimed to evaluate physicians' proficiencies in performing CRA and risk‐based dental referrals.
Design
The study involved a self‐administered questionnaire that elicited participants' demographics and perceptions regarding oral health‐related activities as well as responses to questions pertaining to CRA and referral recommendations via four clinical vignettes (vignettes 1 and 3: low caries risk, vignettes 2 and 4: moderate/high caries risk) of children aged ≤ 2 years.
Results
Participants performed better at CRA than for referral recommendation (p < 0.001). Including a clinical photograph (vignettes 3 and 4) did not improve the accuracy of CRA responses and instead significantly reduced the correct CRA responses for vignette 3 (before: 90.5%, after: 81.7%, p = 0.033). Though for vignette 3, there was an increase in participants making the recommendation to refer for dental evaluation (before: 34%, after: 86%) after being shown the clinical photograph.
Conclusion
Doctors were proficient at determining caries risk but less sure when deciding if a dental referral was required.
Keywords: caries risk assessment, dental care for children, dental caries, paediatrician, primary care physician
Summary.
- Why this paper is important to pediatric dentists
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○Data showed that paediatricians and primary care physicians were able to determine caries risk but were less adept with risk‐based dental referral.
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○Thus, there appears to be a need for inter‐professional education on risk‐based dental referral and perhaps development of a national guideline on risk‐based dental referrals for children ≤ age 2 to ensure that children at the highest risk of developing caries establish a dental home early to lower disease burden in the future.
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1. Introduction
The benefits of establishing a dental home early have been discussed extensively in the literature [1, 2, 3, 4]. In a previous study from Singapore, the authors found that children aged 24–42 months who did not have a dental home were three times more likely to suffer from severe early childhood caries compared to children enrolled in a preventive oral health programme before the age of 18 months [1]. As medical visits by a child in their first year of life are likely to be scheduled earlier and occur more frequently than dental visits, organisations such as the American Academy of Paediatrics (AAP) advocate that paediatricians and family physicians assess caries risk and screen for dental caries in early childhood [5]. Unfortunately, Zhu et al. found that approximately 40% of primary care providers were not referring children in accordance with the AAP guidelines [6]. The reasons cited for low dental referral rates by medical providers were lack of confidence in conducting caries risk assesment (CRA), the preferential use of the presence of clinical signs and symptoms of dental disease (e.g., decay, pain, abscess), and infrequent use of behavioural risk factors to trigger a referral [6, 7, 8]. Several studies have investigated doctors' knowledge, attitudes and practices in paediatric oral health but only two had evaluated the performance of CRA by doctors and its influence on dental referral patterns [6, 8]. In Zhu et al. study, their findings were limited by the lack of validation of the clinical vignettes [6]. In Long et al. study, the medical provider's assessment of the oral conditions of the children was not validated by a dentist [8]. As such, the accuracies of the participants' risk assessments and referral recommendations were unknown.
This study sought to evaluate and compare the abilities of paediatricians and primary care physicians in accurately assessing caries risk and making risk‐based referral recommendations in children aged ≤ 2 years using validated clinical vignettes. The main reason for choosing children of this age group was because they are more likely to visit doctors rather than dentists, and the provision of preventive dental care for children with high caries risk at this age would yield the most benefits.
2. Methods
The cross‐sectional survey was approved by the National University of Singapore Institutional Review Board (NUS‐IRB‐2021‐208) and the inclusion criteria were (i) specialist in paediatric medicine; (ii) primary care physician, which was defined as either a family medicine physician or general practitioner; and (iii) able to understand written English.
A self‐administered online questionnaire was disseminated via email to 476 paediatricians and 2203 primary care physicians on the mailing lists of the College of Paediatrics and Child Health (Singapore), Department of Paediatrics at the National University Hospital, College of Family Physicians (Singapore) and polyclinics within the National University Health System. Participation was voluntary and data collected were fully anonymized. The questionnaire elicited participants' demographics and practice characteristics as well as their knowledge, current practices, opinions and perceived barriers in oral health screening, CRA and dental referral activities. The second part of the questionnaire described four clinical vignettes representing children aged ≤ 2 years of varying caries risk levels (Figure S1). Two vignettes depicted children of low caries risk (vignettes 1 and 3) and the other two described children of moderate or high caries risk (vignettes 2 and 4). For each vignette, the participant provided responses regarding the (i) caries risk (i.e., low; moderate/high or unsure) and (ii) how they would manage based on the child's caries risk. For vignettes 3 and 4, a clinical photograph of the maxillary anterior primary teeth was provided (after) in addition to the dental history to simulate the clinical scenario of the ‘Lift the Lip’ technique [9]. The participants were given a choice to change their CRA and referral recommendation after viewing the clinical photograph.
2.1. Development of Clinical Vignettes
The clinical vignettes were drafted by the research team using established caries risk and/or protective factors and validated via the Delphi technique [10, 11, 12, 13]. Seven local and international paediatric dentistry specialists from diverse backgrounds were invited to rate the appropriateness of the assigned caries risk level for each vignette using a five‐point Likert scale. If experts scored any item 1–3, they were requested to provide a rationale for their choice. Experts were also asked which dental referral recommendation was best suited for each vignette. If experts chose a recommendation that was not aligned with the choice selected by the research team, they provided a rationale for their recommendation. Consensus was deemed to be achieved when a minimum of 70% of the expert panel was in agreement with the proposed vignettes. The questionnaire was piloted on nine doctors for readability and ease of understanding to reduce any ambiguity of the questions.
2.2. Statistical Analysis
Descriptive statistics were used to summarise the data collected. Pearson's Chi‐Square test was used to examine the association of qualitative variables between paediatricians and primary care physicians. McNemar‐Bowker test was used to compare participants' correct and wrong responses to the questions on CRA before and after the addition of the clinical photograph (vignettes 3 and 4). Statistical significance was considered at p < 0.05. All statistical analyses were performed using SPSS Statistics Version 28 (IBM Corp, Armonk, NY, USA).
3. Results
Of the 200 responses received, data from 177 questionnaires were included in the final analysis. Responses that were excluded comprised participants who did not see children ≤ age 2 (n = 19) and those who did not complete the questionnaire beyond the demographics component (n = 4). Of the 177 responses, 32.2% (n = 57) were from paediatricians and 67.8% (n = 120) were from primary care physicians. There were significant differences between paediatricians and primary care physicians with respect to their country of basic (paediatricians: local: 78.9%; primary care physicians: 57.5%; p = 0.005) and specialty medical training (paediatricians: local: 77.2%; primary care physicians: 58.3%; p = 0.028). None were significantly associated with the ability of participants to accurately assess caries risk or make risk‐based dental referral recommendations (Tables S1 and S2).
3.1. Ability to Accurately Assess Caries Risk and Refer Based on Dental History Alone
Regarding summative responses to all four vignettes, participants were significantly (p < 0.001) more likely to provide the correct responses to the question on CRA that is, ‘What is the child's caries risk status?’ (overall: 90.4%; paediatricians: 94.2%; primary care physicians: 75.9%) than for the question on referral recommendation (overall: 67.3%; paediatricians: 88.5%; primary care physicians: 63.0%). Compared to primary care physicians, paediatricians were significantly more likely to provide correct responses to both the questions on CRA (p = 0.019) and referral recommendation (p < 0.001).
For vignettes 2 and 4 (Table 1) which depicted moderate/high caries risk, there was a significantly higher number of correct CRA responses compared to correct referral recommendation responses among paediatricians (vignette 2: CRA 98.2% versus referral recommendation 46.4%, p < 0.001; vignette 4: CRA 94.6% vs. referral recommendation 82.1%, p = 0.039), primary care physicians (vignette 2: CRA 87.0% vs. referral recommendation 27.8%, p < 0.001; vignette 4: CRA 91.9% vs. referral recommendation 63.1%, p < 0.001), and all participants (vignette 2: CRA 90.6% vs. referral recommendation 33.9%, p < 0.001; vignette 4: CRA 92.8% vs. referral recommendation 69.5%, p < 0.001). For vignette 2, paediatricians were significantly more likely to provide the correct response to both the questions on CRA (p = 0.018) and referral recommendation (p = 0.016) compared to primary care physicians. For vignette 4, paediatricians were significantly more likely to provide the correct response to the question on referral recommendation compared to primary care physicians (p = 0.011).
TABLE 1.
Paediatricians' and primary care physicians' responses to the questions on caries risk assessment and referral recommendation by Vignette.
| Responses | All participants N (%) | Paediatricians N (%) | Primary care physicians N (%) | p |
|---|---|---|---|---|
| Vignette 1: Low risk | ||||
| Caries risk assessment | ||||
| Correct | 150 (87.7%) | 52 (92.9%) | 98 (85.2%) | 0.153 |
| Wrong | 21 (12.3%) | 4 (7.1%) | 17 (14.8%) | |
| Referral recommendation | ||||
| Correct | 142 (83.0%) | 49 (87.5%) | 93 (80.9%) | 0.278 |
| Wrong | 29 (17.0%) | 7 (12.5%) | 22 (19.1%) | |
| Vignette 2: Mod/High risk | ||||
| Caries risk assessment | ||||
| Correct | 155 (90.6%) | 55 (98.2%) | 100 (87.0%) | 0.018 |
| Wrong | 16 (9.4%) | 1 (1.8%) | 15 (13.0%) | |
| Referral recommendation | ||||
| Correct | 58 (33.9%) | 26 (46.4%) | 32 (27.8%) | 0.016 |
| Wrong | 113 (66.1%) | 30 (53.6%) | 83 (72.2%) | |
| Vignette 3: Low risk | ||||
| Caries risk assessment | ||||
| Correct | 153 (90.5%) | 51 (91.1%) | 102 (90.3%) | 0.866 |
| Wrong | 16 (9.5%) | 5 (8.9%) | 11 (9.7%) | |
| Referral recommendation | ||||
| Correct | 140 (82.8%) | 49 (87.5%) | 91 (80.5%) | 0.258 |
| Wrong | 29 (17.2%) | 7 (12.5%) | 22 (19.5%) | |
| Vignette 4: Mod/High risk | ||||
| Caries risk assessment | ||||
| Correct | 155 (92.8%) | 53 (94.6%) | 102 (91.9%) | 0.753 |
| Wrong | 12 (7.2%) | 3 (5.4%) | 9 (8.1%) | |
| Referral recommendation | ||||
| Correct | 116 (69.5%) | 46 (82.1%) | 70 (63.1%) | 0.011 |
| Wrong | 51 (30.5%) | 10 (17.9%) | 41 (36.9%) | |
Note: Bold values are statistically significant at the p < 0.05 level.
3.2. Ability to Accurately Assess Caries Risk With Addition of a Clinical Photograph
There was no difference between paediatricians and primary care physicians in their abilities to accurately assess caries risk after being shown the clinical photograph for both vignettes 3 and 4 (Table 2). For vignette 3, there was a significant drop in the frequency of correct answers for all participants after being shown the clinical photograph (before photograph: 90.5%, after photograph: 81.7%, p = 0.033). However, 86% of physicians chose to refer the child for dental evaluation after being shown the clinical photograph despite it being the incorrect referral recommendation versus 34% of physicians choosing to correctly refer the child for dental evaluation despite 90.6% of physicians correctly identifying the caries risk level as moderate/high in vignette 2. The detailed breakdown of participants' responses regarding CRA and referral recommendation for each vignette with or without clinical photograph is presented in Table S3.
TABLE 2.
Paediatricians' and primary care physicians' responses to the question on caries risk assessment before and after clinical photograph.
| Responses | All participants N (%) | Paediatricians N (%) | Primary care physicians N (%) | p * |
|---|---|---|---|---|
| Vignette 3: Low risk ➔ Mod/High risk | ||||
| Before clinical photograph | ||||
| Correct | 153 (90.5%) | 51 (91.1%) | 102 (90.3%) | 0.867 |
| Wrong | 16 (9.5%) | 5 (8.9%) | 11 (9.7%) | |
| After clinical photograph | ||||
| Correct | 138 (81.7%) | 48 (85.7%) | 90 (79.6%) | 0.337 |
| Wrong | 31 (18.3%) | 8 (14.3%) | 23 (20.4%) | |
| p ** | 0.033 | 0.547 | 0.052 | |
| Vignette 4: Mod/High risk ➔ Mod/High risk | ||||
| Before clinical photograph | ||||
| Correct | 154 (92.8%) | 53 (94.6%) | 101 (91.8%) | 0.753 |
| Wrong | 12 (7.2%) | 3 (5.4%) | 9 (8.2%) | |
| After clinical photograph | ||||
| Correct | 157 (94.6%) | 52 (92.9%) | 105 (95.5%) | 0.485 |
| Wrong | 9 (5.4%) | 4 (7.1%) | 5 (4.5%) | |
| p ** | 0.450 | 1.000 | 0.221 | |
Note: Bold values are statistically significant at the p < 0.05 level.
p‐value from Chi‐Square test comparing responses between pediatricians and primary care physicians.
p‐value from McNemar Bowker test comparing responses to questions on caries risk assessment before and after the clinical photograph.
3.3. Oral Health Attitudes, Knowledge and Practice
Majority of participants agreed or strongly agreed that screening children for dental caries (89.2%) and assessing caries risk (83.7%) were within their purview. Compared to primary care physicians, paediatricians were significantly (p < 0.001) more likely to strongly agree that physicians should screen for dental caries (paediatricians: 32.1%, primary care physicians: 6.4%) and assess caries risk (paediatricians: 25.0%, primary care physicians: 4.5%).
Close to half of paediatricians (48.2%) selected age 1 to be the appropriate age for referring a child to a dentist compared to only 27.3% of primary care physicians (p = 0.012). Paediatricians were significantly (all p < 0.001) more likely to participate in oral health‐related activities compared to primary care physicians (Table 3). Enquiring about bottle‐feeding was the most common practice among all participants (44.6%). Overall, the least common activities were enquiring about the use of fluoridated toothpaste daily (15%) and performing CRA and risk‐based referrals (15%). There was no difference between paediatricians and primary care physicians regarding the time that they were willing to allocate to oral health screening and CRA. The majority of participants were only willing to spend < 3 min on oral health screening (83%) and CRA (82.5%).
TABLE 3.
Participation in oral health related activities.
| Oral health related activities | All participants N (%) | Paediatricians N (%) | Primary care physicians N (%) | p |
|---|---|---|---|---|
| Enquire about bottle feeding | ||||
| Never | 25 (15.1%) | 2 (3.6%) | 23 (20.9%) | < 0.001 |
| Sometimes | 67 (40.4%) | 12 (21.4%) | 55 (50.0%) | |
| Often | 48 (28.9%) | 21 (37.5%) | 27 (24.5%) | |
| Always | 26 (15.7%) | 21 (37.5%) | 5 (4.5%) | |
| Enquire about frequency of sweetened snacks and beverages | ||||
| Never | 43 (25.9%) | 3 (5.4%) | 40 (36.4%) | < 0.001 |
| Sometimes | 76 (45.8%) | 22 (39.3%) | 54 (49.1%) | |
| Often | 27 (16.3%) | 15 (26.8%) | 12 (10.9%) | |
| Always | 20 (12.0%) | 16 (28.6%) | 4 (3.6%) | |
| Enquire whether the child's teeth are brushed daily | ||||
| Never | 48 (28.9%) | 6 (10.7%) | 42 (38.2%) | < 0.001 |
| Sometimes | 63 (38.0%) | 21 (37.5%) | 42 (38.2%) | |
| Often | 29 (17.5%) | 14 (25.0%) | 15 (13.6%) | |
| Always | 26 (15.7%) | 15 (26.8%) | 11 (10.0%) | |
| Enquire who does the toothbrushing for the child | ||||
| Never | 74 (44.6%) | 14 (25.0%) | 60 (54.5%) | < 0.001 |
| Sometimes | 55 (33.1%) | 17 (30.4%) | 38 (34.5%) | |
| Often | 21 (12.7%) | 14 (25.0%) | 7 (6.4%) | |
| Always | 16 (9.6%) | 11 (19.6%) | 5 (4.5%) | |
| Determine if toothpaste is fluoridated and being used daily | ||||
| Never | 97 (58.4%) | 21 (37.5%) | 76 (69.1%) | < 0.001 |
| Sometimes | 44 (26.5%) | 17 (30.4%) | 27 (24.5%) | |
| Often | 16 (9.6%) | 12 (21.4%) | 4 (3.6%) | |
| Always | 9 (5.4%) | 6 (10.7%) | 3 (2.7%) | |
| Determine if the child has a dental home/receives regular dental care | ||||
| Never | 76 (45.8%) | 12 (21.4%) | 64 (58.2%) | < 0.001 |
| Sometimes | 56 (33.7%) | 21 (37.5%) | 35 (31.8%) | |
| Often | 20 (12.0%) | 14 (25.0%) | 6 (5.5%) | |
| Always | 14 (8.4%) | 9 (16.1%) | 5 (4.5%) | |
| Screen for dental problems (e.g., lift the lip to check for dental plaque and caries on the front teeth) | ||||
| Never | 64 (38.6%) | 10 (17.9%) | 54 (49.1%) | < 0.001 |
| Sometimes | 65 (39.2%) | 25 (44.6%) | 40 (36.4%) | |
| Often | 26 (15.7%) | 16 (28.6%) | 10 (9.1%) | |
| Always | 11 (6.6%) | 5 (8.9%) | 6 (5.5%) | |
| Conduct caries risk assessment and refer children to a dentist based on their caries risk | ||||
| Never | 82 (49.4%) | 15 (26.8%) | 67 (60.9%) | < 0.001 |
| Sometimes | 59 (35.5%) | 23 (41.1%) | 36 (32.7%) | |
| Often | 19 (11.4%) | 15 (26.8%) | 4 (3.6%) | |
| Always | 6 (3.6%) | 3 (5.4%) | 3 (2.7%) | |
| Refer children to a dentist based on age | ||||
| Never | 73 (44.0%) | 9 (16.1%) | 64 (58.2%) | < 0.001 |
| Sometimes | 68 (41.0%) | 29 (51.8%) | 39 (35.5%) | |
| Often | 16 (9.6%) | 12 (21.4%) | 4 (3.6%) | |
| Always | 9 (5.4%) | 6 (10.7%) | 3 (2.7%) | |
Note: Bold values are statistically significant at the p < 0.05 level.
3.4. Oral Health Training and Confidence Level
There was no difference in the number of paediatricians and primary care physicians who received training for oral health screening and CRA. Overall, only 4.0% of all participants had received training in oral health screening and 2.8% had training in CRA. Paediatricians were significantly more confident than primary care physicians in assessing caries risk (p = 0.004), determining the need for dental referral (p < 0.001) and giving anticipatory guidance (p = 0.001) (Table S4). Overall, the activity in which participants were most confident (i.e., confident or very confident) was providing anticipatory guidance on oral health to parents/caregivers (44.2%). Participants were least confident in evaluating caries risk in children, with 80.6% of them being uncertain or very uncertain.
3.5. Barriers
Overall, the most common barriers were lack of training or skill in determining caries risk factors and status (93.5%) and recognizing dental caries (91.6%), and the lack of a practical CRA and referral checklist/tool (91.0%). Compared to pediatricians, primary care physicians were significantly more likely to report the following barriers: lack of remuneration for assessing caries risk (p < 0.001) and for making a dental referral (p = 0.002), and uncertainty of when a referral is warranted (p < 0.001) and to which dentist or dental clinic the referral can be made (p = 0.002) (Table 4).
TABLE 4.
Perceived barriers to oral health related activities.
| Barriers | All participants N (%) | Paediatricians N (%) | Primary care physicians N (%) | p |
|---|---|---|---|---|
| Lack of training or skill in determining caries risk factors and status | 145 (93.5%) | 46 (88.5%) | 99 (96.1%) | 0.067 |
| Lack of training or skill in recognising dental caries | 142 (91.6%) | 46 (88.5%) | 96 (93.2%) | 0.315 |
| Lack of a practical caries risk assessment checklist/tool | 141 (91.0%) | 46 (88.5%) | 95 (92.2%) | 0.439 |
| Lack of referral checklist/tool | 133 (85.8%) | 42 (80.8%) | 91 (88.3%) | 0.202 |
| Lack of time to perform caries risk assessment | 130 (83.9%) | 44 (84.6%) | 86 (83.5%) | 0.858 |
| Unsure when a dental referral should be made | 120 (77.4%) | 31 (59.6%) | 89 (86.4%) | < 0.001 |
| Low importance parents/caregivers place on dental referrals | 107 (69.0%) | 35 (67.3%) | 72 (69.9%) | 0.741 |
| Unsure which dentist or dental clinic to refer | 98 (63.2%) | 24 (46.2%) | 74 (71.8%) | 0.002 |
| Poor motivation by parents/caregivers to change behaviours | 95 (61.3%) | 36 (69.2%) | 59 (57.3%) | 0.149 |
| Lack of time to make dental referrals | 64 (41.3%) | 17 (32.7%) | 47 (45.6%) | 0.122 |
| Not remunerated for caries risk assessment | 64 (41.3%) | 11 (21.2%) | 53 (51.5%) | < 0.001 |
| Not remunerated for making dental referral | 52 (33.5%) | 9 (17.3%) | 43 (41.7%) | 0.002 |
| Others | 21 (13.5%) | 12 (23.1%) | 9 (8.7%) | 0.014 |
Note: If a participant responded both ‘yes’ and ‘no’ for a particular barrier, those responses were excluded from the analysis. Bold values are statistically significant at the p < 0.05 level.
4. Discussion
Despite a majority of both paediatricians and primary care physicians reporting having no training in oral health screening (96.0%) and CRA (97.2%), they were able to accurately assess the caries risk, as shown by the high frequency of correct responses to the CRA questions (overall: 90.4%). We hypothesise that the ability of the participants to accurately determine caries risk may be because the behavioural caries risk factors presented in the study's vignettes are likely general knowledge and the majority of doctors would be familiar with them, especially if they were parents themselves. Additionally, the nutritional recommendations for general health share some similarities to dietary recommendations for good dental health. For instance, the consumption of sweetened beverages is a common risk factor for childhood obesity and dental caries.
However, unlike the high frequency of correct responses to CRA (90.4%), participants had a significantly lower frequency of correct responses to the question on dental referral recommendation (67.3%). This is concerning, as an accurate assessment of caries risk alone cannot prevent or slow down the advancement of early childhood caries if anticipatory guidance is not provided or children deemed to be of moderate/high caries risk are not referred promptly to the dentist. An evaluation of the responses by vignettes found that the lower frequency was largely attributed to the responses in vignettes 2 and 4, both of which were cases depicting moderate/high caries risk. For these two cases, the frequency of correct responses in vignette 2 (33.9%) was much lower than that for vignette 4 (69.5%) for all participants. The main difference between the two vignettes was that vignette 2 depicted an 11‐month‐old child, while vignette 4 depicted an 18‐month‐old child. We postulate that participants chose not to refer the child to a dentist in both vignettes because of the child's young age (i.e., ≤ 18 months old) and the presentation of only cariogenic habits (e.g., drinking sweet beverages and no brushing of teeth) without clinical signs and symptoms of dental disease. This is corroborated partially by the study's finding that a relatively large proportion of the participants reported that the appropriate age to visit a dentist is at 2 years (rather than 1 year old based on AAP guidelines), as well as Long et al. study, which found that clinical risk factors rather than behavioral risk factors were strongly associated with a referral recommendation [8]. Perhaps a qualitative research study to better understand the reasons for the disconnect between CRA and referral recommendation among doctors is needed. Regardless, these findings suggest that, in addition to training on CRA, inter‐professional training on the appropriate risk‐based action plan is necessary.
Expectedly, paediatricians scored significantly better than primary care physicians at CRA and determining the need for dental referrals likely due to their additional training, higher paediatric patient load, and more active involvement in dental history taking. Additionally, the majority of paediatricians agreed or strongly agreed that they had a role to play in oral health screening (96.4%) and CRA (91.1%). This finding aligns with the existing literature whereby the majority of paediatricians acknowledged that they had an imperative role in identifying dental problems [14, 15].
The Lift the Lip technique has been suggested to be used for dental screening by Alaluusua et al. as the authors found that visible plaque and the presence of decay on the labial surfaces of maxillary incisors at age 19 months were positively correlated to dental caries occurrence at age 36 months and in posterior teeth of 3 to 5‐year‐old children, respectively [9, 16]. To date, there are no studies on the efficacy of the Lift the Lip technique by doctors in children aged ≤ 2 years. In this study, the addition of the clinical photograph to simulate the Lift the Lip technique did not improve the participants' ability to assess caries risk but instead reduced the diagnostic accuracy in participants' responses to Vignette 3. Yet, the addition of a clinical photograph increased the overall referral for dental evaluation, suggesting that the Lift the Lip examination is still a viable route to increase the referral of children for dental evaluation and the early establishment of a dental home. These study's finding suggest that participants found it challenging to recognise incipient dental caries and plaque accumulation, hence, providing a photograph of the teeth did not improve their CRA accuracy. This is supported by the study's finding that 91.6% of participants felt that the lack of training or skill in recognizing dental caries was a barrier in their practice of oral health‐related activities. Additional research to explore the possible factors leading to the decrease in CRA accuracy with the addition of clinical photographs should be performed as more information should expectedly increase rather than decrease accuracy.
This study found that the participant's ability to make accurate referral recommendations depended on their level of participation in enquiring about behavioural risk factors (e.g., bottle feeding, frequency of intake of sweetened foods, daily toothbrushing, use of fluoridated toothpaste). Thus, in the clinical setting where time is a significant challenge as evidenced by over 80% of participants only willing to allocate less than 3 min for oral health screening and CRA and 83.9% identifying lack of time as a barrier, we suggest that using solely behavioural risk factors may be sufficient for dental screening in children aged ≤ 2 years. This is supported by Long et al. who reported that behavioural risk factors were more prevalent in children < 3 years old compared to clinical risk factors [8].
The study's results are limited by its low overall response rate, which may lead to response bias. Possible reasons include survey fatigue, lack of incentive to participate, and time constraints faced by doctors. Additionally, the study should be replicated in other regions and age groups to validate the effect of the Lift the Lip technique on CRA accuracy.
In summary, the study demonstrated that paediatricians were better than primary care physicians at assessing caries risk and making accurate risk‐based referrals. The majority of paediatricians and primary care physicians were able to determine the caries risk status of children from their dental histories alone. However, they did not perform as well when it came to making the appropriate risk‐based dental referral.
Author Contributions
Catherine H.L. Hong, Shijia Hu, Yuqin Liew conceived the research project idea; Chin‐ying S. Hsu, Tammy S.H. Lim, David H.Y. Tan, Tze Lee Tan refined the research idea; Yuqin Liew collected the data; Yufan Sim analyzed the data; and Catherine H.L. Hong and Yuqin Liew led the writing.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Data S1. Supporting Information.
Data S2. Supporting Information.
Funding: The authors received no specific funding for this work.
Data Availability Statement
The data that supports the findings of this study are available in the Supporting Information—S1 of this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. Supporting Information.
Data S2. Supporting Information.
Data Availability Statement
The data that supports the findings of this study are available in the Supporting Information—S1 of this article.