Pediatric Dentistry in Primary Healthcare: Creation,Development,and Evaluation of a Distance Education Course

Abstract

Background:

Oral health in childhood is a major problem for global public health. In Brazil, the prevalence of childhood tooth decay varies from 12% to 46%. Dental care treatment in Brazil is almost the exclusive responsibility of primary healthcare (PHC). Therefore, it is essential these professionals are prepared to conduct restorative, endodontic, and exodontic treatments and preventive care in children.

Introduction:

Children make up a large proportion of the population in territories requiring advanced dental care provided by PHC in Brazil. To care for these patients, it is necessary to have both manual dexterity and technical knowledge of pediatric dentistry. Accordingly, this study aimed to develop a distance course on pediatric dentistry.

Materials and Methods:

A pretest questionnaire consisting of 15 questions was used to assess initial dental knowledge of participants. After completion of a five-module course, participants retook the same initial dental knowledge questionnaire (post-test). Descriptive statistic and paired t test, one-way analysis of variance, and Pearson and Spearman correlation were used, and a significance level of 5% was set.

Results:

The majority of participants completing the five-module course were women who earned specialty degrees beyond undergraduate studies and currently worked in PHC (>5 years). Participant performance on the dental knowledge questionnaire after completion of the five-module course improved pre- to post-test.

Conclusions:

These data suggest that completion of a distance course on pediatric dentistry can be an effective tool for improving knowledge of pediatric dentistry in PHC professionals.

Introduction

Primary healthcare (PHC) has become one of the most equitable and efficient ways of organizing a health system. This healthcare structure is aimed at responding regionally, continuously, and systematically to most of the healthcare needs of a population at both an individual and community need basis.¹ In addition to increased attention given to healthcare, PHC has important effects on cost of the overall healthcare system.²

In 2007, Brazil's Department of Health created the telehealth program aimed at educating professionals in the area of family health strategy (FHS) to strengthen PHC.³ Telehealth offers education and assistance through electronic means to support FHS teams, and aims to develop and evaluate new instruments for permanent and continuing education for healthcare to assess actions of family health teams. In addition, telehealth seeks to identify what educational training is needed by PHC professionals, while also offering support and learning strategies to address these knowledge gaps.³ Other tools such as remote access to resources for diagnostic or even therapeutic support are also offered by telehealth.^4,5

Currently in Brazil, adolescent patients make up a large amount of the population in territories assisted by PHC. These patients also commonly demonstrate health conditions requiring the attention of primary care services. In this context, it is important to highlight that pediatric oral health is a major problem for global public health.⁶ Reports suggest that, in Brazil, the prevalence of childhood tooth decay varies from 12% to 46%, with the age group demonstrating the highest prevalence of tooth decay being 1–3 years.^7,8

As such, to treat these patients, it is necessary to have both manual dexterity and technical knowledge of pediatric dentistry. Because pediatric dentistry is not included in services provided by specialized dental centers, treatment of children is almost exclusive to PHC. Therefore, it is essential these professionals are prepared to conduct restorative, endodontic, and exodontic treatments and preventive care in children.^9,10

In Brazil, there is a high demand for tele-education, which includes the Telehealth Project UFRGS (TelessaúdeRS), where educational topics often related to pediatric dentistry are discussed. The Telehealth Project UFRGS program is a national pole for primary care education composed of activities of tele-assistance, telediagnosis, and tele-education. Thus, it is critical that a distance education course in pediatric dentistry designed for the PHC sector be offered to such professionals. This should lead to improved PHC work quality while increasing access to oral health for this population and avoidance of unnecessary referrals within the healthcare network.⁷

Therefore, this study aimed to create, develop, and evaluate a distance learning course on pediatric dentistry intended for dentists working in PHC offered by the Telehealth Project UFRGS.

Materials and Methods

Type of Study

Interventional study, aimed at examining the situation before and afterward, using the methodology of distance education.

Participants

A survey was conducted among dental surgeons serving as PHC providers in Brazil who enrolled in a course called pediatric dentistry in PHC. Inclusion criteria for participation in the course were being a dental surgeon, being engaged in duties for the Council of Dentistry in the region, and working at a PHC. To analyze the data, only those participants who accepted participation in this through confirmation on an electronic-informed consent form were included. Another important criterion was that they needed to have answered the pretest, a quiz about their personal and professional profiles, and, after the course, the post-test.

Ethical Considerations

This study was approved by the Research Ethics Committee of Federal University of Rio Grande do Sul (assessment 1.302.271)

Intervention

Disclosure and enrolling of the participants

The course content was delivered by means of virtual communication. The 15-day long enrolling period could have been terminated if the maximum number of positions had been fulfilled.

Course structure

The course was offered as a distance education course with the Moodle Platform from Universidade Federal do Rio Grande do Sul being used as a virtual learning environment. The software and online research tool SurveyMonkey^® was used to deliver the pre- and post-test quizzes.

The distance education course was composed of five modules organized by researchers according to pedagogical action plans for every module. The topics covered in each module were (1) management in pediatric dentistry: communication and relationship with the patient, types of crying and management strategies in pediatric dentistry, and behavioral management techniques; (2) dentistry: restorative treatment–treatment decision, conservative treatment of pulp, and restorative materials in pediatric dentistry; (3) endodontics in deciduous teeth: endodontic treatment in deciduous teeth, pulpal treatments conservatives, and radical treatments of pulp; (4) dental trauma: trauma, trauma of hard tissues and support tissues; and (5) planning in pediatric dentistry: treatment and clinical planning and clinical cases.

During the course, two Web conferences were held after Modules 3 and 5, at a time that was synchronized and prescheduled with the participants through the Mconf Web conference system, in optional character, using image and text resources. The Web conferences aimed at providing the opportunity to resolve doubts and to discuss matters raised by the participants through chatting. They were conducted by a professor of pediatric dentistry and a master's student. Each Web conference lasted for 1 h. In cases in which the participants still had doubts, these could be resolved through long-distance consultation requests. Web sessions were not mandatory. Participants were informed about the days and times of the Web sessions, and were free to choose to participate. Questions about the daily clinical practice arose and were discussed in depth by the participants.

Modules were made available to participants weekly. Every video class was also recorded and edited while being made available to participants of the course through the Moodle Platform. The 8-week course consisted of a total of 5 hours of contact per week for a total of 40 hours of course work. Participants were not charged for taking the course in this study. Funding was provided by the Telehealth Project UFRGS, which is linked to a Federal University maintained by the Brazilian Government.

Instruments Used in the Course

Pretest quiz

After reading and signing the informed consent form, participants took the pretest quiz, which was aimed at assessing participant baseline knowledge of pediatric dentistry. The pretest was made available through Moodle Platform and consisted of 15 “true” or “false” questions created by the researchers. The questions referred to topics in pediatric dentistry that would be referred to during the following course sessions while being grouped according to certain themes.

Quiz on the personal and professional profile of the participant

Participants were invited to respond to a quiz about their personal and professional profile during the first week of the course. This quiz was made available through SurveyMonkey. This quiz was available until the end of Module 5.

Post-test quiz

After completion of the 8-week course, all participants took the same quiz they took before taking the course. This was done to assess the level of knowledge gained as a result of taking the 8-week course in pediatric dentistry.

Evaluation of the participants' performance

To pass, the candidate was required to achieve a score of 70% or more, being 40% of the final grade scored by postmodule, and 60% of the final grade scored by the post-test.

Data Analysis

Data referring to the participant characteristics are presented according to absolute and relative frequencies. Continuous variables are presented as mean (±standard deviation) and nominal variables presented as percentages. Paired t tests were used to assess participant quiz performance before and after the course. Correlation analysis among independent variables (gender, country region, time since graduation, age, time working at PHC, and having a specialization course or not) and the dependent variables (performance on the pretest and on the post-test) was evaluated using Pearson correlation.

To verify whether an influence of the exclusion of participants who did not respond to the quiz about the personal and professional profile, the post-test, or both over the obtained results was possible, a one-way analysis of variance (ANOVA) test was carried out, comparing the pretest grades obtained by these excluded participants and the pretest grades obtained by the participants who responded and were included to the research. Statistical procedures were carried out using the SPSS (Statistical Package for the Social Sciences) program, with a 5% significance level.

Results

Initial sample comprised 430 participants who were enrolled in the distance education course. Among these, 15 had their enrollment denied for not being dental surgeons, 42 did not conclude the enrollment steps, and 18 lost their enrollment for not having responded the pretest in due time. From the effectively enrolled 355 participants of the course, 10 did not agree with being part of the research, 89 did not respond to the participant's personal and professional profile, 34 did not respond to the post-test and 2 did not have their pretest detailed results stored by the Moodle Platform, being, thus, excluded from the research. The final sample of this study included in the data analyses was 220 participants.

Table 1 describes the personal and professional profile of the participants. The averages for age, time since graduation, and time working at PHC were 33.3, 9.2, and 6.5, respectively. A large proportion of the sample consisted of female participants who graduated from public universities up to 10 years ago, had specialization course training (among these, most are in the field of collective/public/family health), have been working in PHC for up to 5 years, considered their computer knowledge as good, and having the computer as their most common form of accessing the course.

Table 1.

Personal and Professional Profile of the Participants

	MINIMUM (AGE)	MAXIMUM (AGE)	AVERAGE AGE (STANDARD DEVIATION)
Age	22	62	33.3 (±8.59)
Time since graduation	0	39	9.2 (±8.46)
Time working at PHC	0.08	30	6.5 (±6.00)

			N (%)
Gender
Female			181 (82.3)
Male			39 (17.7)
Place of formal education
Public university			148 (67.3)
Private university			64 (29.1)
Time since graduation
Up to 10 years			142 (64.54)
11 to 20 years			54 (24.5)
More than 20 years			24 (10.9)
Specialization
Yes			143 (65)
No			77 (35)
Field of specialization
Pediatric dentistry			9 (6.38)
Collective/public/family health			77 (54.60)
Pediatric dentistry and collective/public/family health			3 (2.12)
Others			52 (36.87)
Time working at PHC
Up to 5 years			119 (54)
6 to 10 years			56 (25.5)
11 to 20 years			38 (17.3)
21 years or more			7 (3.2)
Computer knowledge
Very good			23 (10.5)
Good			132 (60)
Regular			60 (27.3)
Bad			5 (2.3)
Form of accessing the course
Computer			200 (90.9)
Tablet			49 (22.3)
Cell phone			90 (40.9)

PHC, primary healthcare.

From pre- to postcourse, there was a significant improvement in participant quiz performance (t = 11.221; p < 0.0001) (Table 2).

Table 2.

Average Grades on Pretest and Post-Test (±Standard Deviation)

	MINIMUM	MAXIMUM	AVERAGE (STANDARD DEVIATION)
Pretest	4.00	10.00	7.95 (±1.08)
Post-test	4.69	10.00	8.91 (±0.96)^a

Significant difference (p < 0.005).

It is worth mentioning that when the one-way ANOVA test was conducted after excluding the participants who did not respond either to the profile quiz (p = 0.463) or to the post-test (p = 0.161), there was no significant change in the grades obtained on the pretest by the research participants, which indicates that the exclusion of these participants did not influence the results of this study.

The paired t test was also conducted to analyze the results of each question individually, taking into consideration the average obtained in each one of them on the pretest and on the post-test (Table 3).

Table 3.

Paired t Test Using the Averages of Every Question on Pretest and on Post-Test

MODULE	QUESTION	PRETEST AVERAGE	POST-TEST AVERAGE	PRETEST AND POST-TEST PAIRING (t)	p
1. Handling pediatric dentistry	1	0.6426	0.6639	2.127	0.035
	2	0.6700	0.6700	—	—
	3	0.6304	0.6639	3.110	0.002
2. Cosmetic dentistry—treatment decision	4	0.6243	0.6609	3.056	0.003
	5	0.5817	0.6395	3.499	0.001
	6	0.3533	0.4233	2.411	0.017
3. Endodontics in deciduous teeth	7	0.5116	0.6456	6.839	0.000
	8	0.5086	0.5786	2.998	0.003
	9	0.3868	0.6335	10.506	0.000
4. Dental trauma	10	0.5573	0.6365	4.999	0.000
	11	0.6243	0.6487	1.798	0.074^ns
	12	0.3776	0.4294	2.003	0.046
5. Planning in pediatric dentistry—treatment planning	13	0.6030	0.5147	−4.213	0.000
	14	0.3441	0.5177	6.349	0.000
	15	0.5786	0.6030	1.375	0.171^ns

ns, nonsignificant.

Table 4 presents the participants' percentage of correct answers for each question on pretest and on post-test. Questions that presented the smallest percentage of correct answers were questions 6, 7, 8, 9, 12, and 14.

Table 4.

Percentage of Correct Answers for Each Question on Pretest and on Post-Test

MODULE	QUESTION	% OF CORRECT ANSWERS ON PRETEST	% OF CORRECT ANSWERS ON POST-TEST
1. Handling pediatric dentistry	1	95.9	99.1
	2	100.0	100.0
	3	94.0	99.1
2. Cosmetic dentistry—treatment decision	4	93.2	98.6
	5	86.8	95.5
	6	52.7	63.2
3. Endodontics in deciduous teeth	7	76.4	96.4
	8	75.9	86.4
	9	57.7	94.5
4. Dental trauma	10	83.2	95.0
	11	93.2	96.8
	12	56.4	64.1
5. Planning in pediatric dentistry—treatment planning	13	90.0	76.8
	14	51.4	77.3
	15	86.4	90.0

When evaluating students' performance related to each module (resulting from the sum of the averages obtained in all questions in the thematic unit), all modules differed significantly between pre- and- postcourse (Table 5). Pearson correlations were conducted to evaluate the relationship between independent variables and dependent outcomes. It was observed that the variables age, time since graduation, and time working at PHC presented a statistically significant difference when correlated the grade with the pretest average. This difference, however, was not observed when these variables were correlated with the post-test average.

Table 5.

Paired t Test Using the Averages of the Questions Grouped by Module

PAIRING OF THE QUESTIONS GROUPED BY MODULE	t	p
Module 1	3.626	0.000
Module 2	4.478	0.000
Module 3	11.180	0.000
Module 4	4.741	0.000
Module 5	2.932	0.004

Discussion

Tele-education is one of the learning instruments with the greatest potential for universalization and growth in numerous areas of healthcare education, including oral health. This learning mode refers to the use of interactive technologies to broaden the possibilities of knowledge construction, increasing the access to quality educational materials.¹¹

Expansion of distance education courses and the demand for teleconsultation related to areas of pediatric dentistry received by Telehealth Project UFRGS served as the inspiration for the creation and development of this course. The number of dental surgeons working in PHC practices who enrolled in this course demonstrates the need for these professionals to develop and improve skills related to the field of pediatric dentistry. In this context, Chen et al.¹² note that teledentistry education can be taken as a complement to traditional teaching methods in oral health, showing satisfactory educational outcomes for dentists and dentistry graduate students.

Analysis of dental surgeon profiles that look for distance education courses is of extreme importance. This can help improve the understanding of provider characteristics of practices in a given area, as well as subsidize planning and decision-making related to public health and education in health policies involving dentistry.⁵ According to these data, most participants were female and graduated from public universities,^13,14 despite a large part of offered dentistry courses in Brazil being private.¹⁰ In addition, more than half of the sample consisted of professionals who graduated up to 10 years ago, which implies that these individuals sought to update their base knowledge of the field. Alternatively, this could be taken to suggest that these professionals may not have been qualified to conduct patient care practices as required by patient needs. In this context, a similar profile of working professionals in the Brazilian Public Health system was described by Camargo et al.¹⁵ These authors assessed the effectiveness of digital media education for dentists performing atraumatic restorative treatment by using questionnaires before and after the digital media course. They observed the highest quiz scores occurred in female dentists (p = 0.034) as well as in those who worked for shorter period of time in the public health system (p = 0.042).

Among the professionals with specialization, most are in the collective/public/family health areas, showing that this service is qualified, with the professional improvement toward this approach preconized by PHC. In relation to the knowledge in pediatric dentistry of the professionals enrolled in this course, the questions presenting the smallest percentages of correct answers (smaller than the final average of the pretest) and, consequently, those that represent the greatest difficulties the participants had were questions 6, 7, 8, 9, 12, and 14. Question 6 deals with indicating partial removal of decayed tissue, which is an emerging subject and not widely discussed in pediatric dentistry, especially at PHC. Questions 7, 8, and 9 are the three questions that make up the module about endodontics in deciduous teeth. The lower rate of correct answers indicates that professionals working in PHC present difficulties in this area. Question 12 deals with dental intrusion, a subject highly prevalent among infant patients. Question 14 refers to the planning in pediatric dentistry–treatment planning module, which covers the importance of evaluating the extension of lesions related to decay to make decisions concerning the restoration treatment.

After the professionals finished the distance education course, all these questions had significantly higher percentages of correct answers on the post-test, which attests for the course's effectiveness. Peterson et al.¹⁶ described similar results in a study developed with graduate students in dentistry using a Web-based atlas of pediatric dentistry with clinical and radiographic images containing illustrations. The aim of this study was to evaluate the students' satisfaction with the online learning model. The results showed that students preferred to use the online manual in comparison with traditional texts, indicating that distance education strategies in pediatric dentistry present positive results.

Improvement in participant knowledge of pediatric dentistry in this study after implementation of the 8-week course suggests that distance education courses may be an effective alternative for teaching in PHC practices. Use of this learning approach may result in improved qualifications of dental professionals while potentially being useful for improving scientific evidence in this area of clinical practice. Nevertheless, it is worth mentioning that the sample used in this study was of convenience. Therefore, because this study was targeted for a specific group of PHC providers, it is not possible to confirm that, if this study had been applied to the service network, the obtained results would have resulted in the same outcomes. Future studies should look to implement a random sampling technique using the same intervention.

These data suggest that the telehealth program is an efficient tool for the wide scale production and application of distance education courses for dental surgeons across the country. Since one of the objectives of the Telessaúde Program is to identify the real learning needs of PHC professionals and to offer support and learning strategies for these needs,⁴ offering distance education courses for dental surgeons may be an effective strategy to meet the needs of these professionals. This study also shows the importance of evaluating the demand of teleconsultations carried out by professionals over time, as the repetition of themes and subjects might represent the need for carrying out another approach related to this theme, as was the case with the creation of the distance education course pediatric dentistry at PHC.^15,17

The average age of the participants was 33.3 years. It was, however, a very heterogeneous sample, with ages ranging from 22 to 62 years. The Pearson correlation conducted between age and pretest average showed a statistically significant negative correlation, meaning that the older the participant was, the smaller his/her average grade in the pretest was. In contrast, after the distance education course, the Pearson correlation between age and average grade on the post-test was positive and had no statistically significant association.

The distance education course in pediatric dentistry designed for PHC professionals led to favorable results for participants. Knowledge of pediatric dentistry appeared to improve after the 8-week course session, which suggests that this may be an effective approach for providing education to the professional working in the PHC sector. In addition to demonstrating the capability of reaching professionals in hard-to-reach areas, overall this learning method reaches a greater number of participants compared with traditional teaching methods.

Conclusions

These data suggest that knowledge of pediatric dentistry improves after 8 weeks of online course learning in individuals engaged in delivering healthcare services in the PHC sector. Distance education can be an effective tool for providing educational tools needed by professionals working in the PHC sector.

Footnotes

Acknowledgment

The authors thank TelessaúdeRS for the technical support.

Disclosure Statement

The authors declare that they have no conflicts of interest in article publication. The authors declare that they did not obtain funding for this study.

References

Brazil. Ministry of Health. Ordinance no 2488. [In Portuguese]. 2011.

Santos

, Souza

, Alves

, Santos

. Telehealth: An instrument of assistance and permanent education. [In Portuguese]. Belo Horizonte, Brazil: UFMG, 2006.

Haddad

, Skelton-Macedo

, Abdala

, Bavaresco

, Mengehel

, Abdala

, et al. Formative second opinion: Qualifying health professionals for the unified health system through the Brazilian Telehealth Program. Telemed J E Health, 2015; 21:138–142.

Fontanive

PVN

. Needs in permanent education perceived by medical professionals of the family health strategy teams of the municipalities of the Telessaúde-RS Project. [In Portuguese]. Porto Alegre, Brazil: Federal University of Rio Grande do Sul, 2009.

Haddad

. Dentistry in the training policy of health professionals, the role of Teleodontology as a tool of the teaching-learning process and the creation of the Telepathy nucleus of FOUSP. [In Portuguese]. São Paulo, Brazil: University of São Paulo, 2011.

Touger-Decker

, Van Loveren

. Sugars and dental caries. Am J Clin Nutr, 2003; 78:881S–892S.

Losso

, Tavares

MCR

, da Silva

JYB

, Urban

. Early and severe caries in childhood: An integral approach. [In Portuguese]. J Pediatr, 2009; 85

Fernandes

, Pereira

, Souza

, Ramos-Jorge

, Marques

, Ramos-Jorge

. Severity of dental caries and quality of life for toddlers and their families. Pediatr Dent, 2017; 39:118–123.

Brazil. Ministry of Health. Secretariat of Health Care. Department of Basic Attention. Manual of specialties in oral health. [In Portuguese]. Brasília: Ministry of Health; 2008:128.

10.

Morita

, Haddad

, Araújo

. Current profile and tendencies of Brazilian surgery in Maringa, Brazil. [In Portuguese]. Brazil: Dental Press, 2010.

11.

Wen

. Telemedicine and telehealth: A panorama in Brazil. [In Portuguese]. Inform Pública, 2008; 10:07–15.

12.

Chen

, Hobdell

, Dunn

, Johnson

, Zhang

. Teledentistry and its use in dental education. J Am Dent Assoc, 2003; 134:342–346.

13.

Costa

, Prado

MCM

, Andrade

, Araújo

EPP

, Silva Junior

, Gomes Filho

, et al. Profile of the professional of superior level in the teams of the Family Health Strategy in Montes Claros. [In Portuguese]. Rev Bras Med Fam Comunidade, 2013; 8:90–96.

14.

Castro

RCL

, Knauth

, Harzheim

, Hauser

, Duncan

. Assessment of the quality of primary care by health professionals: Comparison between different types of services. [In Portuguese]. Cad Saúde Pública, 2012; 28:1772–1784.

15.

Camargo

, Aldrigui

, Imparato

, Mendes

, Wen

, Bönecker

, Raggio

, Haddad

. E-learning used in a training course on atraumatic restorative treatment (ART) for Brazilian dentists. J Dent Educ, 2011; 75:1396–1401.

16.

Peterson

, Kaakko

, Smart

, Jorgenson

, Herzog

. Dental students attitudes regarding online education in pediatric dentistry. J Dent Child, 2007; 74:10–20.

17.

Miller

. The assessment of clinical skills competence/performance. Acad Med, 1990; 65:563–567.