The effect of education upon dentists' knowledge and

attitude toward fissure sealants

Najat M. A. Farsi, BDS, MSc
Preventive Dental Sciences Department, Faculty of Dentistry, King Abdulaziz University, PO Box 1540 jeddah 21441, KSA

Sealants are highly effective in preventing dental caries in pits and fissures of teeth. It has been shown, however, that sealants are not widely used by dentists. This study aimed to inform dental professionals about sealants and to evaluate the effect of such information on dentists' knowledge, attitude and use of sealants. A total of 190 dentists were surveyed to determine their knowledge and attitude toward sealants. Respondents were randomly assigned to an "Education" group who received education materials in contrast with the "No Education" group who did not receive any until after the education phase. After 12 months, 105 dentists responded to the post-intervention survey. Comparison between the two surveys showed that dentists' knowledge increased significantly in the "Education" group. No difference was detected in the dentists' knowledge in the "No Education" group. However, dentists' attitude toward sealant use did not significantly improve in either of the groups. It is, therefore, concluded that continuing education was more likely to change dentists' knowledge rather than attitude and behaviour. Efforts to encourage sealant use by dentists should continue, but with the recognition that changes in behaviour occur over a long time and that other external factors in the professional environment may affect ihe rate of chance.

Epidemiological data show that the prevalence of dental caries in most developed countries has declined in recent decades.^1,3 It has been sugg­ested that the use of fluoride in various forms has been largely responsible for this decline. Unfortunately, preventing tooth decay on the occlusal surfaces of teeth remains a problem for the practising dentist because fluoride is less effective on these surfaces. Fissure sealants are highly effective in preventing caries in pit and fissures⁴',⁸ and the manage­ment of incipient carious lesions.⁹ However, in spite of the scientific evidence supporting their effectiveness, their use by dentists have been minimal.¹⁰ In the United States, it was reported that only 10% of school children in Tennessee had sealant on their teeth,¹¹ while only 12% had sealants in North Carolina.¹² Chestnutt et al¹³ in 1994 reported that only 10.2% of the Scottish school children had sealants which is even higher than the level of sealants reported in 1996 in other parts of the United Kingdom.¹⁴ A more recent study showed an increased use of sealant between 30-50% in the United Kingdom.¹⁵
There are many reasons for the sparse use of sealants in caries prevention. Lack of know­ledge about sealants has frequently been cited as a possible determent to its adoption.¹⁶¹⁸ Lack of public knowledge and belief about the efficacy of dental sealants also influence paren­tal acceptance of sealants for their children.¹⁹ Continuing education has been proposed as a method of increasing sealant utilization among practising dentists.²⁰²⁴ Results of these studies suggest that continuing education may have positive effects upon knowledge, opinion and behaviour but without a well-designed research using an adequate control group, the extent of these effects remains speculative.
The caries experience among children in various parts of the Kingdom of Saudi Arabia has been reported to be high.^25,27 However, the adoption of pit and fissure sealants for preven­tive purposes by the dentists' in the Kingdom has not been evaluated. The author examined 2450 school children from grades 1-9 and found less than 5% of them had sealants (unpublished data). The present study aimed to provide information about sealants to the dentists working in private dental practices in the City of Jeddah and to determine whether dentists' knowledge, attitude and use of sealants could be modified by education.

Subjects
A list of names and addresses of private dental clinics in the city of Jeddah was obtained from the Ministry of Health. The clinics were contacted by phone to obtain information regarding the number of dental professionals in each clinic. All dentists (312) in the private practice constituted the initial sample. This sample was surveyed to determine level of knowledge, attitude towards sealants and use of sealants. The respondents were randomly assigned to two equal groups, one group was offered educational material and the other served as a control group. After 12 months, a post-intervention survey was conducted to identify differences, if any, in knowledge, atti­tude and sealant use between the two groups.

Questionnaire
The survey questionnaire was developed, reviewed and pilot-tested among 15 dentists who were not included in the main study. The questionnaire was modified based on the results of the pilot test. A 19-item questionnaire was developed for the study based on questions addressing knowledge, attitude and sealant usage from other investigations.¹⁷'²²'²⁷-²⁸ The pre-intervention questionnaire consisted of six questions to assess dentists' perception of the value of sealants, the practicality of their application, their cost effectiveness and accep­tance by patients. Seven questions were used to measure dentists' knowledge about sealants retention, appropriate teeth for sealing, sealant longevity and their relation with water fluori­dation. A three-point scale (1 to 3) was used with the categories "Agree," "Undecided" and "Disagree." Respondents were requested to record their year of graduation from dental school. Data on dentists' current sealant use was obtained by asking for estimates of the average number of patients aged 18 years and younger that the respondents treated per week and the percentage of those who received sealants. If sealants were not being applied in the office, the respondent was asked to choose from a list of 9 reasons why this was so.¹⁸-²²-²⁹ The post intervention questionnaire contained the same questions as the pre-intervention survey. In addition to these, however, the dentists were asked to indicate how valuable the different components of the education materials used in the study have been to them. A composite score for attitude was created by summing the correct responses of each dentist to the questions regarding attitude, then dividing it by the total number of possible responses (six). The result was then multiplied by 100 to arrive at an attitude score with a range of 0-100. Mean attitude scores from pre-and post-intervention surveys were recorded. A composite score for dentist's knowledge about sealants was developed with the same proce­dure and the correct responses were divided by seven.

Educational Material
The education materials consisted of a news­letter with updated information from scientific studies about sealants and some suggestions for improved decision-making and maintenance based on materials and technique changes. The second portion of the education materials was a plaster model with two plastic teeth of lower first permanent molars one was sealed and the other unsealed. These models were provided to supplement health education materials in the office, and to allow the dentist to visually demonstrate sealants and their effect on pit and fissures to patients. The third portion was the Arabic patient education material in the form of pamphlets with a written introduction about the high caries incidence in the pit and fissure surfaces of the molars, their prevention using fissure sealants, the most suitable age of sealant applications and the cost-benefit effect of sealants. Dentists who were assigned to the "Education" group received the educational material as they responded to the pre-interven-tion questionnaires. The "No Education" (Con­trol) group received educational materials after the completion of the post-intervention ques­tionnaire.

Data Analysis
Only the data obtained from dentists who responded to both surveys were included in the analysis. All incomplete responses were elimi­nated. Comparison procedure using paired t-test was used to determine significant differences between the "Education" and "No Education" groups with respect to knowledge and attitude scores and the percentage of patients receiving sealants. The Chi-square test was used to assess the usefulness of the different components of the education materials. P <0.05 was regarded as significant.

The final sample which responded to both questionnaires consisted of 105 dentists, 64 in the "Education" and 41 in the "No Education" group. Table 1 shows a comparison between the "Education" and "No Education" groups on the basis of gender and years since graduation from dental school. Regarding sex distribution, 57.8% of the "Education" group were male in comparison to 46.3% in the "No Education" group. This difference was not statistically signi­ficant (P = 0.37). Since there was no difference in sex distribution between the two groups, they were combined together in all the analysis. The answers to the question regarding years since graduation varied from 2 to 25 years in the "Education" group and from 4 to 27 years in the "No Education" group with a mean of 14.3 years and 14.1 years, respectively.

The mean attitude and knowledge scores and the mean percentage of young patients recei­ving sealant in the pre and post-intervention surveys are shown in Table 2. The two groups exhibited almost identical attitude scores for pre-intervention survey (57.5 and 56.4 percent of the Education and No Education group, respectively). Although the attitude values of both groups increased slightly, there were no significant differences between pre- and post-intervention results in either of the two groups.

At the post-intervention survey, while the "Education" group had significantly higher knowledge score than the pre-intervention survey (P <.0005), the "No Education" group exhibited no difference between the two surv­eys. In the pre-intervention survey, results showed the proportions of patients aged 18 years or younger who were receiving sealants: 28.1 and 26.5 percent for the dentists in the "Education" group and "No Education" group, respectively. Sealants placement values were not significantly different at P > .05. Comparing the use of sealants in the pre- and post-intervention surveys showed that the use of sealants had increased slightly in both groups, but these differences were not statistically significant. At pre-intervention survey, about 30% of the total sample were not using any sealants. Those respondents who reported non use of sealants were asked to rank the most important reasons for non-usage (Table 3). The four most frequent first choices for not using sealants were: 1) Patients have difficulty under­standing the value of sealants (27%); 2) Patients are unwilling to pay for sealants (21.2%); 3) Sealants do not last long in the mouth (17.6%); and 4) I do not treat enough children (16.4%).

A question was posed to the "Education" group to evaluate the usefulness of the various educational components of the project. Almost 81 percent of the dentists found the education materials to be useful. The models were repor­ted to be of highest value with 84.6% of respon-

dents reporting them to be useful (Table 4). Respondents were somewhat less enthusiastic about the usefulness of the written patient education materials. While none of the dentists considered the model to be useless, 5.8% judged the written material as useless. The differences in the usefulness of the three components were, however, not statistically significant (x² = 2.25; df = 4; P = .69).

The study sample was representative of the private sector's general dentists and since the subjects were randomly assigned to the two groups, the results could be regarded as being representative for this population. Although many of the variables of interest were acquired by a self-report method, this project has helped to promote the diffusion of sealant technology into dental practice as well as the understanding of the effectiveness of continuing education for dentists. The pre-intervention questionnaire was limited to two pages to increase response rates. The response rates of initial and final questionnaires (61% and 66%, respectively) were comparable with those of other surveys¹⁷²² which used questionnaires of similar length. However, higher response rate was reported by Cohen (37.6%) who used a 12-pages questionnaire.²⁸

Respondents' gender and year of graduation were associated in some surveys with the level of sealants use.¹⁷-²² In the present study, there were no significant differences in the respon­dents' gender nor mean of years since gradua­tion between "Education" and "No Education" groups. Findings from   the   pre-intervention   survey indicated that awareness of sealants is mode­rately low among respondents. There is a great degree of confusion surrounding the facts about sealant. Results showed that education pro­grams are effective in increasing dentists' know­ledge acquisition as evidenced by the improve­ment in knowledge scores which were signi­ficantly higher among the "Education" than the "No Education" group. These findings are similar to those reported earlier.²²-³⁰ Results showed a slight but not significant improvement in the attitude scores in the second survey in both groups. These results are also similar to the findings from a sealant initiative performed in North Carolina³⁰ and by Lang et al.² In those investigations, small but non significant increase in attitude values were found following education programs. The authors concluded that attempts to change attitudes present a challenging objective for any intervention and probably requires sustained repetitive activities over a long time.

As to the use of sealants, almost 70% of the respondents stated that they were currently using sealants. However, when the level of use is quantified, it becomes apparent that sealants are still under-utilized by the majority of dentists.

Sealants use was not increased by partici­pation in the educational program. Although the time between the pre- and post-intervention surveys may have been insufficient to capture changes in behaviour, evaluation periods may need to be years in duration rather than months. Clearly, the issue of patients' accep­tance and willingness to pay for sealants were the concerns of the respondents who were not using sealants. The reasons given for lack of usage are similar to those reported in the litera­ture.¹⁷²⁸ Reinforcement in patient dental health information specially sealant awareness is nee­ded. In Saudi Arabia, the media would be an influential agent in the dissemination of sea­lants information to the public. The significant effect of the media as the primary source of information about sealants was reported by several investigators.³¹-³²

From this study, it can be concluded that conti­nuing education is likely to improve dentists' knowledge, but would have little effect upon their attitudes toward sealant use. The follo­wing approaches may be beneficial: