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Factors That Drive Dentists towards or Away from Dental Caries Preventive Measures: Systematic Review and Metasummary

Factors That Drive Dentists towards or Away from Dental Caries Preventive Measures: Systematic Review and Metasummary

  • Uhana Seifert Guimarães Suga, 
  • Raquel Sano Suga Terada, 
  • Adriana Lemos Mori Ubaldini, 
  • Mitsue Fujimaki, 
  • Renata Corrêa Pascotto, 
  • Adelia Portero Batilana, 
  • Ricardo Pietrobon, 
  • João Ricardo N. Vissoci, 
  • Clarissa G. Rodrigues
PLOS
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Abstract

Background

Dental caries is a serious public health concern. The high cost of dental treatment can be avoided by effective preventive measures, which are dependent on dentists’ adherence. This study aimed to evaluate the factors that drive dentists towards or away from dental caries preventive measures.

Methods and Findings

This systematic review was registered in PROSPERO (CRD42012002235). Several databases as well as the reference lists and citations of the included publications were searched according to PRISMA guidelines, yielding 18,276 titles and abstracts, which were assessed to determine study eligibility. Seven qualitative studies and 41 surveys (36,501 participants) remained after data extraction and interpretation. A total of 43 findings were abstracted from the reports and were grouped together into 6 categories that were judged to be topically similar: education and training, personal beliefs, work conditions, remuneration, gender, place of residence and patients. The main findings for adherence based on their calculated frequency effect sizes (ES) were teamwork (21%) and post-graduation (12%), while for non-adherence were biologicism (27%), and remuneration for preventive procedures (25%). Intensity ES were also calculated and demonstrated low prevalence of the findings. Quality assessment of the studies demonstrated that the methodological quality, particularly of surveys, varied widely among studies.

Conclusions

Despite the questionable quality of the included reports, the evidence that emerged seems to indicate that further education and training coupled with a fairer pay scheme would be a reasonable approach to change the balance in favor of the provision of dental caries preventive measures by dentists. The results of this review could be of value in the planning and decision making processes aimed at encouraging changes in professional dental practice that could result in the improvement of the oral health care provided to the population in general.

Introduction

Dental caries is considered a serious public health problem with significant impact on the quality of life that causes pain and suffering, leads to the loss of school and working hours and affects social relationships [1]. Dental caries is still one of the most prevalent diseases of the oral cavity, afflicting 60 to 90% of school-age children and the vast majority of adults in industrialized countries [1], [2]. The distribution of oral diseases varies among different parts of the world and within the same country or region [3], and according to the availability and accessibility of oral health services [1]. Dental caries is a most prevalent oral disease in several Asian and Latin-American countries, while it appears to be less common and less severe in most African countries [3]. Risk factors for oral diseases include an unhealthy diet, tobacco use, harmful alcohol use and poor oral hygiene, as well as social determinants [1]. In all countries, the oral disease burden is significantly higher among poor and disadvantaged population groups [4].

The treatment of dental caries requires restorative procedures that represent a significant cost in many high-income countries, where oral health can account for 5 to 10% of all public health expenditure [4]. For the majority of low-income nations, the cost of treating caries with the traditional method of restorative dentistry is beyond their financial capabilities, as most of these countries can not finance an essential package of health care services for their children [5]. The high cost of dental treatments can be avoided and caries prevalence can be more effectively tackled by effective prevention and health promotion measures. However, although information on the various etiological factors involved in the development of caries and strategies for its prevention have become widely available, much of the population in many parts of the world is still affected by the disease [6], and the global incidence of dental caries in school-age children remains high [4].

It has already been shown that dentists have poorly contributed to the reduction in the prevalence of dental caries [7]. However, dentists have the potential to influence what their patients know and do regarding dental caries prevention [8], and are often necessary especially in individual prevention. Knowing the reasons that drive dentists away from performing prevention and those that facilitate its adoption can bring an important contribution towards the implementation of dental caries preventive programs.

Thus, the aim of this systematic review was to analyze studies that have investigated the factors that drive dentists towards or away from dental caries preventive measures and conduct a metasummary of the results found.

Materials and Methods

Protocol and registration

This systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement [9], and was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42012002235.

Eligibility criteria

The inclusion criteria were as follows: 1) publications methodologically designed as a “qualitative study” or “survey”, qualitative studies classified as those whose findings were abstracted from unstructured data, i.e., individual or group interviews, while surveys were those studies whose findings were compiled from structured questionnaires; and 2) publications reporting factors that drove dentists (public and private) towards or away from incorporating dental caries preventive measures in their practice. The following exclusion criteria were applied: 1) publications in which the research subjects were dental technicians, doctors, nurses or dental students, and 2) publications presenting factors related to preventive measures such as the use of sealants, mouthrinses, or water fluoridation investigated in isolation.

Literature search

The following electronic databases were used for the selection of the primary studies: PubMed, EMBASE, PsycoInfo, Scielo, Scopus, Web of Science, BBO, Lilacs and York. To ensure the widest possible search, no language filters were applied [10]. The reference lists of the retrieved studies were searched for additional publications, and the citations were also analyzed using Google Scholar. The authors of included studies were contacted by email for the identification of additional studies.

Search strategy

The following terms were used in the search strategy: “dentist”, “dentists”, “general dental practitioner”, “general dental practitioners”, “dental caries”, “prevention”, “oral health”. MeSH terms were used along with the listed entry terms to construct a highly sensitive search strategy. Terms related to the study type were not used because the term “qualitative research” was only introduced in EMBASE in 1988 and as a MeSH term in PubMed in 2003. The complete search strategy used for the PubMed database is shown in Appendix S1.

Study selection

Two reviewers (USGS and ALMU) independently read all retrieved titles, abstracts, and full-text articles. If one assessor regarded a publication as having met the inclusion criteria, the full text was obtained. Abstracts considered as potentially eligible, as well as those that did not supply enough information, were reserved for the assessment of the full-text article. Any differences concerning eligibility after the full text was evaluated were resolved through consensus, and when differences still persisted, a third reviewer (RSST) was consulted before a final decision was reached.

Quality assessment

The quality of the selected studies was assessed by classifying each study according to items adapted from Bennett et al., (2010) [11] for surveys, and the Joanna Briggs Institute Qualitative Assessment and Review [12] for qualitative studies.

The quality assessment of included surveys considered the inclusion of the following items: i) research question justification; ii) explicit research question; iii) clear objectives; iv) description of the methods used to analyze data; v) method used to administer the research instrument (questionnaire); vi) place and date of the study; vii) method described well enough to be replicated; viii) reliability of evidence; ix) validity of evidence; x) method used to verify data entry; xi) use of codification; xii) sample size calculation; xiii) method for selecting the sample; xiv) description of the study population; xv) description of the research instrument; xvi) description of the research instrument development; xvii) instrument pre-test; xviii) instrument reliability and validity; xix) scoring method; xx) informed consent obtained; xxi) ethics approval; and xxii) evidence of ethical treatment of research participants; and xxiii) sample representativeness.

The items analyzed in the qualitative studies were: i) correspondence between the methodology and the indicated philosophical perspective (theory); ii) correspondence between the methodology and the research question or objective; iii) correspondence between the methodology and the methods used for data collection; iv) correspondence between the methodology and data presentation and analysis; and v) correspondence between the methodology and interpretation of the results. Other considerations included statements that: vi) placed the researcher culturally or theoretically; vii) indicated researchers’ influence on the study or vice-versa; viii) demonstrated the representation of participants and their voices; ix) showed the investigation was ethically performed according to current criteria or, in more recent studies, the evidence of ethical approval by recognized institutions; and x) indicated that conclusions were drawn from research reports or from data analysis or interpretation.

The items above were verified and classified as definitely present (yes), partially or unclearly present (not clear), or definitely not present (no). Studies that presented a prevalence of “yes” answers (>50%) in the quality assessment were deemed to have a low risk of bias, studies that did not clearly present many of the items assessed were classified to have a moderate risk of bias, while studies that presented a prevalence of “no” answers (>50%) were considered to have a high risk of bias.

Data extraction

Two reviewers (USGS and ALMU) independently conducted data extraction. General information such as authors, year of publication and first author geographic region were collected from each study. Additionally, the following specific characteristics were also collected: objective, type of study, place where the research was carried out, interventions, number of participants in the sample, inclusion and exclusion criteria, participant characteristics, data collection, data analysis, main results, and authors’ conclusions.

Data analysis

Qualitative metasummary is a quantitatively oriented aggregation of qualitative findings originally developed to accommodate the different characteristics of qualitative studies and surveys [13]. Qualitative metasummary includes the extraction, grouping, and formatting of findings and the calculation of frequency and intensity effect sizes (ES), which permits to produce mixed research syntheses and to conduct a posteriori analyses of the relationship between reports and findings [13].

After the extraction of results from the included studies and the grouping of relevant findings, categories (concise but comprehensive representations) concerning the factors that drive dentists towards or away from carrying out dental caries preventive measures were developed. The categories concerned not only dentists, but also their views of how the factors studied affected their patients. Qualitative data analysis software (ATLAS.ti 7) was used to codify the themes that emerged from the analysis.

To assess the relative magnitude of the extracted results, frequency ES was calculated by taking the number of studies containing a particular finding (minus the studies derived from a common parent study and representing a duplication of the finding) and dividing this number by the total number of included studies (minus the reports derived from a common parent study and representing a duplication of the finding), and expressed as a percentage.

After that, to ascertain which findings reports contributed to the final set of abstracted themes, intensity ES of each report was also calculated. This information is useful for various a posteriori analyses: for example, to determine whether any findings were derived from largely “weaker” studies, which reports contributed most of the findings with the largest frequency effect sizes across reports, and which reports contained findings no other reports contained. Intensity ES calculation was performed by: i) dividing the number of findings contained in the study by the total number of findings across all studies; and ii) by dividing the number of findings with effect sizes >25% contained in that study by the number of findings with effect sizes >25% across all studies.

Results

Study selection

The search of electronic databases yielded 18,276 references. After removing duplicates and assessing titles and abstracts, 106 publications were considered potentially eligible. Full texts were retrieved and analyzed for eligibility. After analysis of the reference lists and Google Scholar citation, 35 additional publications were selected and their full text retrieved and analyzed. Ninety-two publications were excluded for the following reasons: 1) the design of 22 publications did not meet the criteria of a “qualitative study” or “survey”; 2) the research subjects in 11 publications were not dentists; 3) 46 publications did not report the factors that drive dentists towards or away from dental caries preventive measures; 4) the full text of five publications could not be retrieved; and 5) eight publications presented the same sample population. A total of 48 publications were selected comprising seven qualitative studies [14][20] and 41 surveys [8], [21][60]. The electronic contact with authors of included publications did not result in any additional studies. Figure 1 summarizes the process of literature identification and selection.

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Figure 1. Flowchart showing the number of publications identified, retrieved, extracted, and included in the final analysis.

https://doi.org/10.1371/journal.pone.0107831.g001

Study characteristics

Information on the included studies (sampling, intervention, objectives, outcome and risk of bias) is presented in Table 1 (qualitative studies) and Table 2 (surveys). The total number of participants in the seven qualitative studies included in this review was 390. The studies presenting the largest number of participants (311) were Threlfall et al. 2007 [19] and Threlfall et al. [20]. Other included qualitative studies presented populations that varied between 2 and 28 participants. The total number of individuals participating in the selected surveys was 36,111. Surveys, contrary to qualitative surveys, presented a much wider range of participants, varying from as few as 15 [42] to as many as 4,850 [22].

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Table 1. Publication characteristics of the qualitative studies included in the analysis.

https://doi.org/10.1371/journal.pone.0107831.t001

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Table 2. Publication characteristics of the surveys included in the analysis.

https://doi.org/10.1371/journal.pone.0107831.t002

The included qualitative studies and surveys covered a wide geographical area with a total of 28 countries, including Australia (nine publications) [14], [15], [18], [25][29], [33], United States of America (nine publications) [21], [22], [31], [34], [39], [43], [44], [48], [58], England (six publications) [17], [19], [20], [30], [40], [42], Wales (four publications) [16], [23], [32], [57], Brazil (three publications) [24], [55], [56], Iran (three publications) [36][38], Mongolia (two publications) [59], [60] and Spain [54], Finland [45], Korea [8], Malaysia [49], Northern Ireland [35] and Romania [46] (1 publication each). Six publications [41], [47], [50][53] were multicenter studies or surveys involving participants from Denmark, Iceland, Norway, Sweden, Belgium, China, Czech Republic, Germany, Ireland, Madagascar, México, Singapore, South Africa, Tanzania, and Thailand.

Quality assessment

Heat maps showing the gradient of quality indicators for each individual survey and qualitative study included in the analysis are shown in Figures 2 and 3, respectively. Most surveys did not present many of the quality items assessed. A total of 24 studies were judged to present high risk of bias, while 17 studies presented low risk of bias (Table 2). All the qualitative studies, on the other hand, included in the analysis presented the majority of the quality items investigated, with 6 studies deemed to have low risk of bias and only 1 considered to have moderate risk of bias (Table 1).

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Figure 2. Heat map showing a gradient of quality indicators for each individual survey included in the analysis.

Colors vary from white (No), light blue (Not Clear) and blue (Yes) representing the three categories used in the quality assessment.

https://doi.org/10.1371/journal.pone.0107831.g002

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Figure 3. Heat map showing a gradient of quality indicators for each individual qualitative study included in the analysis.

Colors vary from white (No), light blue (Not clear) and blue (Yes) representing the three categories used in the quality assessment.

https://doi.org/10.1371/journal.pone.0107831.g003

Frequency Effect size

After analysis and codification of the 48 included publications, a total of 43 relevant findings were extracted. Findings were then grouped together according to categories which were judged to be topically similar. Grouped findings and their calculated frequency ES are presented in Table 3. The categories of findings to affect dentists’ motivation to perform or not preventive measures in their patients involved: dentists’ dental education and training, personal beliefs on prevention, remuneration, work conditions, gender, place of residence and also the factors that dentists believed to drive patients towards or away from performing preventive measures.

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Table 3. Abstracting, formatting, grouping in categories, and frequency effect sizes (ES) of findings.

https://doi.org/10.1371/journal.pone.0107831.t003

The findings with the highest frequency ES to drive dentists away from performing preventive measures were “biologicism”, (27%), “low pay” (25%), “time since graduation” (22%), and “male dentists” (19%). Whereas, “team work” (21%), “post-graduation” (12%), and “professional understanding of the benefits” (12%) were identified as the main reasons for dentists adherence to preventive measures. The factors for dentists’ adherence or non-adherence to dental caries preventive measures are graphically shown in Figure 4.

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Figure 4. Factors that drive dentists towards or away from performing preventive measures.

Graph theory-based figure showing the relation among qualitative studies and surveys included in the metasummary model. Squares represent the individual studies included, and circles the emerging factors. Size of each individual marking indicates its effect size (ES) in the model; larger markings being more recurrent. Studies presenting lower intensity ES (prevalence) appear further from the center, while studies with higher intensity ES closer to the center of the figure.

https://doi.org/10.1371/journal.pone.0107831.g004

The main factor that dentists believed keep patients from performing preventive measures were “lack of understanding of the benefits” (17%), “age/small children” (12%), and “patient lack of motivation” (8%). While “parents’ motivation” and “patients’ age” (4%) were the reasons to lead to patients towards the same preventive measures. Figure 5 graphically illustrates the factors that dentists believed to drive patients towards or away from performing preventive measures.

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Figure 5. Factors dentists believed to drive patients towards or away from performing preventive measures.

Graph theory-based figure showing the relation among surveys included in the metasummary model. Squares represent the individual studies included, and circles the emerging factors. Size of each individual marking indicates its effect size in the model; larger markings being more recurrent. Studies presenting lower intensity ES (prevalence) appear further from the center, while studies with higher intensity ES closer to the center of the figure.

https://doi.org/10.1371/journal.pone.0107831.g005

Intensity effect sizes

Calculated intensity ES are presented in Table 4. The publication that presented the highest intensity ES, i.e., that presented the highest number of themes relative to the total number of themes, was Murtomaa [43] with a score of 40%, followed by Nettleton [14] and Sbaraini [15] with 26%, and Threlfall [16], [17] with 23%. Among the 48 selected publications, 18 had scores between 8% and 22%, and 26 publications had scores below 8%. Only one finding (biologicism) presented effect size >25%, which resulted in intensity ES >25% = 100% in 13 studies, while intensity ES for the remaining studies was 0%.

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Table 4. Intensity effect sizes (ES) in relation to all themes and themes with frequency effects sizes >25%.

https://doi.org/10.1371/journal.pone.0107831.t004

Discussion

This systematic review and metasummary of qualitative studies and surveys analyzed factors that drive dentists towards or away from dental caries preventive measures.

Surveys and qualitative research differ in how data are obtained. The minimally structured and open-ended interviewing style typically associated with qualitative studies allows an unlimited number of responses, yielding data with a wider range of responses concerning a target event. In contrast, the highly structured and closed-ended questionnaire typically associated with surveys limits the number and specifies the nature and direction of responses, producing data with a narrower range of responses. Seeing all of the findings belonging to one topic together preserves the complexity of the findings. The methodology used in this systematic review allowed the aggregation and interpretation of descriptive findings, which were comparable among themselves [13]. A diversity of findings were abstracted from the selected studies (Table 3) that were analyzed and their potential relevance in understanding which factors drive dentists towards or away from performing preventive measures were commented.

The findings of this systematic review indicate that the reasons for dentists’ adherence to providing prevention are multifactorial and dependent on how and where the study was performed. Nonetheless, it is important to point out the limitations imposed by the quality of the selected reports. The lack of standardization, together with a lack of adequate description of the study methodology, negatively affected the quality assessment, with most of the selected surveys (58%) included in this review being judged to have a high risk of bias. This clearly demonstrate that studies following well established criteria for the conduction of surveys with validated instruments are necessary to better understand dentists motivation or lack of motivation towards preventive measures.

Qualitative studies, on the other hand, were judged to present low risk of bias, with most studies presenting the items analyzed. The drawback concerning this type of study was that fact only a handful of reports were retrieved from the literature. The advantage of qualitative studies is that, due to its design, they may bring to the surface perceptions, feelings, and opinions that are sometimes impossible to be captured by surveys. The included qualitative studies covered just three countries (England, Wales and Australia), limiting the generalizability of findings. Well-designed qualitative studies performed in lower-income countries would significantly add to the understanding of this matter.

A high percentage of studies (54%) had a low intensity frequency, indicating low prevalence of the findings (Table 4). This limitation was compensated by the diversity of findings found in the studies. This multiplicity of findings accounting for dentists’ attitude towards prevention abstracted from the selected reports may be explained by the methodological variability of the reports and the wide geographic area covered.

Nonetheless, despite the low calculated frequency (Table 3) and intensity (Table 4) effect sizes, two main categories of findings have emerged as being relevant to the reasons for adherence or non-adherence to preventive measures. Dental education and training has emerged as the most important category to affect dentists’ attitude to their perception of how to conduct their activities. It seems clear that when dentists are continuously engaged in their professional and educational development, the more open they are to the new demands of the profession, and more likely to embrace prevention in their daily routine [31], [36], [55], [59], [60]. As a result, their education and training have a direct effect on their personal beliefs and vision of prevention as something beneficial for the patient with associated professional satisfaction. In contrast, however, the ways dentists are being remunerated for dental caries preventive measures need to be examined more carefully. The findings in this study demonstrated that low or no remuneration for preventive measures may be an important hindrance to their motivation. This is in agreement with the findings of a recent Cochrane revision, which have indicated that financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists [61]. Thus, a combination of continuous education and training coupled to an acceptable pay scheme would seem to be a reasonable approach to increase dental professionals’ adherence to dental caries preventive measures.

It is expected that this study may contribute to the understanding of factors that can drive dentists towards or away from performing dental caries preventive measures. Moreover, this information may then be used as a useful reference for planning and decision making aimed at changing dental practice and improving the oral health care provided to the general population.

Supporting Information

Author Contributions

Conceived and designed the experiments: RSST MF RCP RP CGR. Performed the experiments: USGS ALMU RSST. Analyzed the data: USGS RSST MF RCP CGR. Contributed reagents/materials/analysis tools: RSST USGS JRNV CGR APB. Wrote the paper: USGS RSST MF RCP CGR.

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