Evaluation of an educational intervention in oral health for primary care physicians: a cluster randomized controlled study

Oral disease may manifest in a variety of forms including including dental caries, periodontal disease and oral mucosal lesions including oral cancer [1]. They pose a serious problem in communities and negatively impact individual quality of life, particularly in low-income populations [1, 2]. Since primary care providers and family physicians are in frequent contact with patients, engaging them would be an efficient approach in oral health promotion programs [2]. In addition, the common risk factor approach (CRFA) considers common health determinants for preventive measures in a multi-professional collaboration [3]. A number of recent reports have emphasized the importance of integrating the dental and medical professions and involving all health professionals in public oral health care (OHC) [4‐8]. Although physicians have shown a willingness to learn about OHC and to provide preventive measures for their patients [5, 9], they receive limited training in this field, and medical curricula often include only limited information on OHC [5, 7, 10‐13].

Previous studies have examined the evidence related to oral health promotion and showed oral health education programs to improve primary care staff’s knowledge of oral health issues [14‐17]. Moreover, research has shown that specifically planned oral health care education increases physicians’ knowledge and may help them promote children’s oral health among deprived populations in developed countries [7, 15]. Knowledge retention after educational interventions, however, remains uncertain [16].

Research has shown continuous medical education (CME) to be an effective way to increase physicians’ knowledge and to improve the provision rate of preventive dental services by pediatric health care providers. The effectiveness of such programs in countries with developing health care systems and where primary care physicians in the position of family physicians for deprived populations has not yet been studied [10, 13, 17, 18].

Our aim was to implement an evidence-based OHC interactive educational seminar for physicians and analyze its impact on the physicians’ retention of OHC knowledge.

Altogether 121 physicians who were working in the public health centers of the non-affluent part of the city participated in the baseline study (response rate: 92%). Of these, 106 physicians completed and returned the outcome questionnaires (response rate: 88%) post-intervention (Group A: n = 38, Group B: n = 32, Group C: n = 36).

Women comprised a clear majority of the physicians in all three groups: 63% in group A, 78% in group B, and 75% in group C (p = 0.331). The mean age of the female physicians was lower than that of the males (35.4 years vs. 44.5 years; p <  0.001). Most of the women (80%) were working in the public sector only, whereas most of the men (70%) worked in both the private and public sectors (p <  0.001).

At baseline, only 3% of the physicians in group A knew the correct answer to the question “Pacifier sucking in under-four-year-old children is a risk factor for dento-alveolar malformation”; the percentage of correct answers for group B was 6%, and for the control group, 14%. Nobody knew that “Using fluoride toothpaste is more important than the brushing technique for preventing caries” in group A, while 3% in group B and 17% in control group answered correctly to this question.

Instead, 97% of physicians in group A, 88% in Group B, and 94% in control group knew that “The frequency of sugar consumption has a greater role in producing caries than does the total amount of sugar consumed” and 90% in group A, 88% in Group B, and 100% in control group knew “the reason of adding fluoride to toothpaste”. The percentage and frequency of the physicians’ correct responses to each knowledge questions in the three domains at the baseline and outcome data collection are shown in Table 1 for the two intervention and control groups.

In group A, the highest differences (68%) in the physicians’ correct responses before and after the intervention was related to the question “The bacteria that cause dental decay usually transmit from mother to the child” followed by; “Using fluoride toothpaste is more important than the brushing technique for preventing caries” with 63% difference; “antihypertensive drugs increase the risk of dental caries” with 58% difference; and “The first signs of decay are white spots or lines on teeth surfaces” with 50% difference.

The highest difference in percentage of correct answers was 19% in Group B and 11% in control group occurring for one single question in medical domain. The difference was “0” for 6 questions in control group.

The mean difference between knowledge total scores before and after the intervention was higher in Group A compared to the Control group in all three domains (p <  0.001) but not in any domain for group B compared to the control (Table 2).

Table 3 shows that when background factors and intervention grouping were included in the linear regression models predicting the outcome variables, group A intervention clearly increased the oral health knowledge scores in all three domains and the total knowledge score (p <  0.001). In addition, the physicians who had acquired lower knowledge scores at the baseline, revealed higher increase in their knowledge after the intervention. The models revealed no associations between the background variables (age, gender, working profile) and the knowledge change.

Family physicians may play a crucial role in reducing oral health problems for their covered population. This randomized interventional study showed that an OHC educational seminar for the physicians effectively improved their OHC knowledge and their knowledge retention after 4 months. Integrating oral health promotion into existing preventive programs improves individual access to OHC prevention, especially among underprivileged groups [22].

Previous studies have shown that the oral health knowledge of physicians in various countries such as Canada, Iran, Italy, Saudi Arabia, and the USA is insufficient [5, 9, 10, 12, 13]. Historically, oral health has operated independently from medicine, and physicians seldom collaborate with dentists [23]. In most countries, children see a primary care physician about ten times for health screenings before their first birthday [24]. In addition, many at-risk groups do not regularly visit the dentist, whereas contact with medical practitioners, including family physicians, is more common [25].

Deepening physicians’ understanding of the relationship between the oral cavity and the rest of the body [24] and training them to perform oral examinations, counsel patients, and refer them to dentists when needed, primary care physicians can help reduce oral health disparities [26]. This information should also become part of the university medical curriculum or continuing medical education (CME) for recertification activities.

Since medical curricula often lack sufficient oral health education [26, 27], CME may be an opportune point for inclusion of this topic. CME in oral health for physicians would increase the number of professionals who are prepared to help with prevention and early recognition of oral diseases, especially for at-risk groups and target populations such as children. Various programs have been introduced in countries such as the USA to provide oral health CME for pediatricians [15]. Physicians in public health centers typically have very busy workdays, which may have kept them from studying the pamphlet at all. Despite this, the CME seminar provided them an opportunity to focus on the educational material they received.

The present physicians receiving the CME seminar, along with the booklet and pamphlet reminder, demonstrated greater knowledge than did the group who received the pamphlet only or the control group. Our result is consistent with the results of prior studies, which have shown an increase/improvement in physicians’ OHC knowledge after 2 hours of didactic training [28]. Another similar study revealed that physicians provided preventive services for their patients after receiving 90 min of CME in OHC [15]. Our findings may be related to the effect of the interactive educational seminar, which gave the physicians the opportunity to ask and get answers from the lecturer as well as clear examples of and demonstrative slides. Previous research has also shown that motivation is an important factor in learning [29], and that the motivating and learning approach has proved useful in dental settings [30]. In CME, the traditional seminar is considered the most common method, though it may carry the limitations of an inactive audience. In comparison to the traditional lecture-based, the interactive methods such as workshops, online courses, hands-on practical training, are more effective in transferring information and changing physicians’ practice [31, 32]. In our study, we eliminated the weakness of traditional seminar by holding an interactive session and using an educational booklet as a learner-centered method of self-study. Use of reminder pamphlet in our interactive seminar group could have served as a call to action to motivate the physicians and support knowledge retention among the participants [33].

Our study included DHCs located in the non-affluent part of the city. People in the non-affluent parts of the city cannot afford private care; consequently, access to private practice is more limited [27]. Therefore, the number of public health centers and patient turn-over is higher in the non-affluent regions. Another study showed that physicians working in the non-affluent area, who may have been treating children from high-risk population, were more willing to receive OHC information [5]. There was no gender or age difference in the physicians’ total knowledge score increase which is the same as in the research findings from Italy in which the knowledge increase was the same for both sexes [13]. Our questionnaire was validated in previous studies [5]. Due to their busy program, the physicians were permitted to complete the questionnaires on their own time. As all the questionnaires were anonymous, the physicians had no obligation to find the correct responses in any other way than through their own knowledge, thus avoiding any influence on the findings. Physicians are busy in their daily work, and this study suggests taking advantage of distance education to provide easy access and the potential for interaction in future studies.

The primary care physicians in our study attained a higher level of OHC knowledge after participating in an educational program. These findings suggest that physicians’ CME programs and curricula should include OHC topics if they aim to promote oral health, especially among non-privileged populations.