Document Type


Date of Degree

Fall 2011

Degree Name

PhD (Doctor of Philosophy)

Degree In

Oral Science

First Advisor

Damiano, Peter

First Committee Member

Weber-Gasparoni, Karin

Second Committee Member

Murph, Jody

Third Committee Member

Nothwehr, Faryle

Fourth Committee Member

Fang, Qian


The past few decades have witnessed an increased focus on the importance of oral health on the social, psychological and developmental well-being in children. Although effective and advanced dental prevention measures and treatment options are increasingly available, dental decay remains one of the most common chronic childhood diseases in the United States and around the world. Recently, the World Health Organization Assembly called attention to the significant burden oral disease has maintained in all countries around the world. Additionally, multiple studies have described disparities in oral health with a disproportionate amount of dental disease concentrated in children with special health care needs, those that live with poor families or that live in isolated or rural communities. In response to this issue there has been renewed focus on combating access to oral health care issues. One approach that has been suggested is the utilization of non-dental health professionals in assessing oral health, performing basic preventive steps and referral of high-caries risk children for further care. These non-dental professionals are often in a better position to evaluate children at an early age, are more likely to see poor children early and to provide care for them on a continuing basis when compared to dentists. However, several barriers have been mentioned in the literature that prevent or deter these non-dental health professionals from taking on a more active role in this access to care issue. Of which has been a reported lack in oral care education and training for medical care professionals. Additionally, collectively few studies have specifically identified the importance of different suggested influencing factors.

In our present study, three main analyses were conducted. The first analysis assessed the oral-health knowledge, practices, and factors influencing the ability and willingness of Iowa pediatricians' to assess and refer high caries-risk children. In which, a 22-item survey was mailed to all licensed pediatricians in Iowa. Chi-square statistics and logistic regression models were used to analyze data. On questions regarding comfort levels when performing oral-health related practices on children under 3, physicians reported high levels of comfort with all specified issues. The majority of respondents routinely gave the name of a dentist to the caregiver when referring, where as only 4% made use of local care coordination services and only 9% actually made the dental appointment. Sixty-five percent referred all children 12 months or older to a dentist in accordance with AAPD and AAP guidelines. The ability to locate a dentist willing to accept Medicaid or uninsured children was noted as the major referral barrier. Bivariate and multivariate logistic regression analyses indicated that pediatricians who had higher frequency of seeing oral-health problems (p=0. 0.0488), greater mean total number of children seen per week (p=0.0431), and believed that children should have their 1st dental visit no later than 12 months of age (p=0.0196) were more likely to make frequent referrals to a dentist compared to their counterparts. The second analyses assessed Saudi medical interns' oral-health knowledge, and other factors influencing their ability and willingness to perform oral-health related practices for high caries-risk children. In which, a 15-item survey was emailed to all eligible graduating fifth year medical students at King Khalid University Hospital to address these areas of interest. Chi-square statistics and logistic regression models were used to analyze data. Similar to our first study physicians noted high levels of comfort with all specified oral health practices. However, students generally rated their medical training fair or poor in preparing them for oral-health assessments compared. Additionally, although 90% of respondents noted that the role of primary physicians in counseling/referring children with oral health was important; 60% did not agree with the AAPD and AAP guidelines that state that all children should be referred to a dentist by 12 months of age. Multivariate logistic regression analyses revealed several statistically significant variables that predict the likelihood of performing various oral-health related practices. The choice of public-health oriented future clinical goals, the level of oral-health knowledge, how interns rated their oral health training in medical school, and the average number of children seen per week, all - to varying degrees - proved important predicator variables for the likelihood of performing them once in practice. In our third study focus was placed on assessing the effectiveness of an electronic educational intervention on improving primary care practitioners' knowledge, willingness, and comfort levels in identifying children who are at high risk for developing dental caries. Following the educational program, a 16-item survey was emailed to all participants to address the areas of interest. Bivariate correlation and linear regression were used to analyze data. Respondents gave a higher percentage of correct responses to the knowledge questions post-intervention compared to pre-intervention with an average increase of 63%. Additionally, nearly all respondents agreed with the statement that all children 12 months and older should be seen by a dentist in accordance the AAP & AAPD. Furthermore, physicians noted improved levels of comfort with all specified oral health practices. Most notable, following the educational intervention, 91% of respondents rated them-selves as comfortable in counseling, compared to only 25.6% that did so before the educational program. The only exception on comfort issues pertained to performing emergency treatments on young children with a majority of interns (92%) still considering themselves as neutral or uncomfortable in doing so. Multiple linear regression analyses revealed several statistically significant variables that predict the likelihood of performing various oral-health related practices. Increased oral health knowledge, higher self-perceived comfort levels and seeing oral-health problems more frequently all proved important predicator variables for the likelihood of performing oral-health related services.

Collectively, these three analyses lead us to several main conclusions and future education recommendations. Educating medical practitioners and students about basic oral health recommendations and referral guidelines provides an excellent opportunity to alert medical professionals about the importance and timing of these dental referrals. Ultimately, earlier referrals by physicians can help improve dental utilization among high risk children, especially among lower income and rural families. Additionally, providing these medical professionals with experience opportunities in assessing the oral health of young children may improve both physician willingness and likelihood to perform various oral health practices for young children. Overall, increasing both knowledge and personal experience of training physicians' could lead to greater comfort levels in dealing with oral health issues affecting young children. Furthermore, establishing effective care coordinator services to assist in linking various health care professionals more directly; may also increase physician willingness to assess and refer high-caries-risk children by making the referral process easier for physician offices. This step helps in saving time and effort, two deterrents noted by physicians.


Access to Care, Children Teeth, Dental Caries, Inter-disiplinary cooperation, Oral Health, Physicians


2. ix, 199 pages


Includes bibliographical references (pages 190-199).


Copyright 2011 Yousef Yousef