Awareness,knowledge and practice of evidence-based dentistry amongst dentists in Kuwait

Authors


  • This paper is based on an undergraduate research study by the first two authors. It was judged the best student paper at the 8th Annual Conference of the Kuwaiti Division of the IADR in 2008 and competed for the IADR/Unilever Hatton Award at the General Session of the IADR, Orlando, FL in 2009.

Ridwaan Omar
Faculty of Dentistry
Kuwait University
PO Box 24923
Safat 13110
Kuwait
Tel: +965 24986756
Fax: +965 25326049
e-mail: romar.k@hsc.edu.kw

Abstract

This study assessed the awareness, knowledge and practice of evidence-based dentistry (EBD) amongst dentists working in the public sector in Kuwait. Of the 150 randomly selected dentists from all five health districts in Kuwait who had originally been approached, 120 participated by completing a pre-tested, self-administered questionnaire (80% response rate). Whereas 60.9% of the group stated that they practice EBD most of the time, fewer (40.8%) had a reasonable understanding of EBD based upon tested knowledge scores of EBD-related topics. Clinical decisions appeared to be mostly based on the clinician’s own judgment (73.3%) rather than on evidence-based sources such as PubMed (28.3%) or the Cochrane Library (6.7%). A number of within-group differences were noted, with women (P < 0.05), those working in a particular district (P < 0.05), those with <10 years’ experience (P = 0.05), those whose first dental qualification had been obtained in Kuwait (P < 0.05), and those who had had any EBD training (P < 0.05) showing greater knowledge of EBD. Training in EBD was felt necessary by a majority of the group, and this may be facilitated if dental centres have access to evidence-based sources to remove some of the possible barriers to implementation of EBD.

Introduction

As healthcare providers, it is important that physicians and dentists offer the best possible care for their patients. This requires not only a sound educational base but also a good source of current best evidence to support their treatment recommendations (1). However, decisions made in healthcare are generally not made as a result of good evidence (2). Yet, even if best evidence is obtained, it is the translation of that knowledge into implementation that will positively impact the quality of healthcare (3).

Evidence-based practice (EBP) is said to be the current best approach to provide interventions that are scientific, safe, efficient and cost effective (1, 3). The reasons for this are assumed to be through improvements in physicians’ and dentists’ skills and knowledge, as well as in the communication between patients and their physicians about the rationale behind clinical recommendations made (1, 2, 4, 5).

The American Dental Association defined evidence-based dentistry (EBD) as an approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences (6). Whilst studies have attempted to assess the levels of awareness and implementation of EBD amongst various groups of clinicians in different settings (7, 8), it is not possible to generalise the results to all clinicians.

There appears to be a general dissatisfaction regarding the quality of primary healthcare services provided in Kuwait (9). For example, Kuwait has been found to have one of the highest levels of antibiotic resistance (10), most probably due to the overuse of antibiotics. This suggests that clinical practices in Kuwait may not be as evidence-based as would be wished. However, there are no data on the level of EBP in Kuwait, and in particular, we do not know the levels of awareness, knowledge and practice of EBD amongst dentists. The aim of this study was to explore the level of awareness and practice of EBD amongst general dentists and dental specialists working in the Ministry of Health, as well as to attempt to identify the barriers to practising EBD in Kuwait.

Methods

A four-page English language questionnaire comprising 25 questions was designed to assess awareness, knowledge and practice of EBD amongst dentists working in the Ministry of Health. Eight questions were on socio-demographic factors, eight related to knowledge of EBD, seven about attitude towards and practice of EBD, and two related to barriers to implementing EBD. Some questions were taken from previously tested questionnaires; some examples of which were ‘What percentage of your clinical practice do you feel is currently evidence-based?’ (a continuous scale of 100% to 0% was provided); ‘What do you think are the major barriers to practising evidence-based medicine (EBM) in general practice?’ (seven options were provided ranging from ‘lack of time’ to ‘lack of access to EB sources’); and ‘Have you ever received formal training in search strategy?’ (yes/no options were provided) (11). To confirm validity and to determine acceptability and clarity of our questionnaire, a pilot study was performed on seven staff members of the Faculty of Dentistry, Kuwait University, and accordingly minor modifications made.

The Ministry operates polyclinics and specialty centres in each of the five districts across the country, viz. Capital, Hawalli, Farwaniya, Ahmadi and Jahra. The number of facilities in each district varies approximately according to its resident population, although dentist:population ratios are not uniform across the districts given the changing population distribution in a rapidly growing country. For historical reasons, the polyclinics provide emergency, preventive and basic dental care, whilst specialist centres receive referrals of patients in need of comprehensive and more complex therapies (12).

According to available data, there were 742 general dentists and specialists working in the Ministry in 2008. It was estimated that sampling 15—20% of this population would allow the findings to be representative of the entire population of dentists working in the public health sector, giving the study a power of 80% at 95% confidence level, with about 7% margin of error. On this basis, a representative sample of 150 dentists working in five specialty centres and 15 polyclinics (on the basis of one specialty dental centre and three polyclinics per district) were approached after applying a multi-stage random sampling method as the selection criteria. The random selection of polyclinics/specialty centres was performed using a computer-based random number generator (GraphPad Software, 2007; GraphPad Software Inc., La Jolla, CA, USA). A total of 120 dentists completed the questionnaire (response rate of 80%). Ethical consent was obtained from the Ministry of Health as well as from the Faculty of Dentistry Research and Ethical Review Committee. Earlier, permission to conduct the survey had been obtained from the chief dentist at each polyclinic/specialty centre.

Data were collected through personal visits by two of the research group (IMH, MYS) to each of the facilities. The period of the survey was from 7 to 28 July 2008 and targeted both day-shift and evening-shift dentists. The average time required by participants to complete the questionnaire was 20 min, but because of the large number of patients in some clinics, some participants required longer than that.

Statistical analyses of the data were performed using Statistical Package for the Social Sciences (SPSS version 16.0; SPSS Inc., Chicago, IL, USA). The descriptive statistics are presented as percentages and means. To reflect the level of EBD knowledge amongst dentists, EBD knowledge scores were computed by weighting each knowledge item according to our perception of its relative importance (see Appendix). Thus, question 10 (regarding the EBM pyramid) was assigned a score of 4 as it had four elements to be ranked in correct order: if the order given was wrong, a score of 0 was given. On the other hand, question 13 was about four of the tools that are useful for EBD and was given a score of 1 for each tool. Questions 18—22 were on the fundamentals of EBD and were either true or false: each was assigned a score of 2 for a correct response and 0 otherwise. The total score in this algorithmic construct for EBD knowledge ranged from 0 to 21.

A mean EBD knowledge score for the group was obtained and used to categorise participants into subgroups with scores less than, and more than, the group mean. Knowledge scores were found to be normally distributed. Therefore, different factors, including gender, country of first dental degree, district, years of experience, field of dental practice, and self-reported practice of EBD, were compared with participants’ standing in relation to the mean group EBD knowledge score, using t-test and ANOVA, as appropriate. A two-tailed P-value <0.05 was considered statistically significant.

Results

The largest number of dentists was from Capital (31.7%) and the fewest from Ahmadi (12.5%) (Table 1). Male to female dentist ratio was 1.7:1. Age varied considerably, with the majority (82.5%) being 40 years of age or less. In terms of education, 30% had obtained their first dental degree from Asia (viz. India and Pakistan) and 28.3% from Arab countries other than Kuwait (viz. Egypt, Syria, Lebanon, Jordan, Iraq and Saudi Arabia). General dentists comprised 55.8% of the sample, the rest being specialists. Only 32.5% had more than 10 years of clinical experience, the rest having 10 years or less of clinical experience.

Table 1.   Socio-demographic and educational characteristics of the study sample (n = 120), and total number of general dentists and dental specialists working by district (n = 742)
CharacteristicsStudy sampleTotal no. of dentists
Frequency%Frequency%
District
 Capital3831.715621.0
 Hawalli2016.719326.0
 Farwanya2823.315320.6
 Ahmadi1512.514819.9
 Jahra1915.88711.7
Gender
 Male7663.3  
 Female4436.7  
Age (years)
 <305243.3  
 31—404739.2  
 41—501613.3  
 >5054.2  
First dental degree
 Kuwait1714.2  
 USA1915.8  
 Europe1411.7  
 Asia3630.0  
 Other Arab countries3428.3  
Field of practice
 General dentist6755.8  
 Specialist5344.2  
  Periodontics65  
  Orthodontics1411.7  
  Endodontics1915.8  
  Prosthodontics43.3  
  Pedodontics75.8  
  Oral and maxillofacial surgery32.5  
Clinical experience (years)
 ≤108167.5  
 >103932.5  

Reported level of daily clinical practice of EBD was 60.9% (Table 2). As many as 58.4% claimed to have had some form of EBD training, but a large number also wanted to have more formal EBD training. A majority noted that there were many barriers to learning about, and applying EBP.

Table 2.   Frequencies of self-reported extent to which evidence-based practice (EBP) is being practised and factors related to EBP (n = 120)
QuestionFrequency%
  1. EBD, evidence-based dentistry.

To what extent do you practise EBD?
 Almost always86.7
 Most of the time6554.2
 Sometimes3831.7
 Rarely97.5
Are you aware of various clinical guidelines?
 Always4235.0
 Sometimes6655.0
 Never1210.0
Have you had any EBD training?7758.4
What are the barriers to practising EBD?
 Lack of time6856.7
 Lack of training8066.7
 Lack of access to evidence8167.5
 No personal computer in workplace10688.3
 No access to internet connection11394.2
 No access to international journals11091.7
 Lack of training in critical appraisal10285.0
Are you willing to have EBD training?10587.5

Level of knowledge of a selection of EBD tools was poor, with more than 70% reporting that they had no idea of, and had no interest in knowing about the items listed. Further, over 13% reported that it is not relevant for their clinical practice to know anything about meta-analysis, confidence interval, P-value or odds ratio (Table 3).

Table 3.   Frequencies of self-reported understanding of some tools used in evidence-based dentistry (EBD) (n = 120) (% in parentheses)
EBD toolsNo idea, and not willing to knowNo idea, but willing to knowHave a vague ideaGood understanding
P-value17 (14.2)38 (31.7)35 (29.2)30 (25.0)
Relative risk8 (6.7)35 (29.2)48 (40.0)29 (24.2)
Sensitivity10 (8.3)34 (28.3)32 (26.7)44 (36.7)
Meta-analysis16 (13.3)48 (40.0)37 (30.8)19 (15.8)
Odds ratio21 (17.5)41 (34.2)38 (31.7)20 (16.7)
Publication bias16 (13.3)41 (34.2)35 (29.2)28 (23.3)
Confidence interval16 (13.3)36 (30.0)38 (31.7)30 (25.0)

The mean EBD knowledge score for the group was 9.03, with 40.8% of the group being above the mean. In comparing those above and below the mean score in relation to a number of characteristics, there were a number of significant differences, viz. district (P < 0.05), gender (P < 0.05), country of first dental degree (P < 0.05), clinical experience (P = 0.05), and whether the dentist had EBD training or not (P < 0.05) (Table 4). More than half of the Capital and Farwanya dentists had knowledge scores above the group mean. In addition, more female dentists, graduates from Kuwait and Europe, dentists with <10 years of clinical experience, and those who had received some EBD training, had knowledge scores above the group mean. The only characteristic that showed no significant difference was in the field of practice.

Table 4.   Frequencies of subgroups of dentists with evidence-based dentistry (EBD) knowledge scores above and below the group mean knowledge score (mean 9.03), and association of level of EBD knowledge by socio-demographic and other characteristics
CharacteristicsGroup mean scoreAbove mean score (n = 49)Below mean score (n = 71) P
District
 Capital10.520 (52.6)18 (47.4)<0.05
 Hawalli7.34 (20)16 (80)
 Farwanya10.816 (57.1)12 (42.9)
 Ahmadi7.76 (40)9 (60)
 Jahra6.63 (15.8)16 (84.2)
Gender
 Male8.1524 (31.6)52 (68.4)<0.05
 Female10.725 (56.8)19 (43.2)
First dental degree
 Kuwait13.213 (76.5)4 (23.5)<0.05
 USA8.77 (36.8)12 (63.2)
 Europe10.07 (50)7 (50)
 Asia7.69 (25)27 (75)
 Other Arab countries8.213 (38.2)21 (61.8)
Field of practice
 General dentist9.230 (44.8)37 (55.2)NS
 Specialist8.919 (35.8)34 (64.2)
Clinical experience (years)
 ≤109.7838 (46.9)43 (53.1)0.05
 >107.511 (28.2)28 (71.8)
Had any EBD training?
 Yes10.1838 (50)38 (50)<0.05
 No7.0511 (25)33 (75)

There was no consistent association between EBD knowledge and the stated use of various information sources. Whereas referring to medical journals such as Lancet or the BDJ had no association, using sources like the Cochrane Library (P < 0.05), PubMed/Medline (P < 0.05) and evidence-based websites (P < 0.05) were significantly associated with higher EBD knowledge scores. On the other hand, whilst using official (national) guidelines was not significantly associated, using international guidelines for clinical practice was associated with higher knowledge scores (P < 0.05).

In response to a selection of statements on some common EBD-related topics, at the group level, most participants did not know the hierarchy of strength of evidence. Just over half the group thought that EBD is based on expert opinions, although 75.8% knew that the EBD process helps in the selection of the optimal treatment for a patient (Fig. 1). Compared to the total group, the frequency of those with knowledge scores above the mean group score responding correctly was greater in all of the statements.

Figure 1.

 Percent positive responses to a selection of evidence-based dentistry (EBD)-related statements by the total group (n = 120) and by those in the sample who had an EBD knowledge score above the group mean (n = 49) [1: On the basis of the evidence, antibiotics should be prescribed to a localised swelling related to a decayed tooth (answer: no); 2: On the basis of the evidence, amalgam should be banned from practice (answer: no); 3: EBD includes accurate diagnosis and selection of optimal treatments for individual patients (answer: yes); 4: EBD practice ignores experience (answer: no); 5: EBD is based on expert opinion (answer: no); 6: Rank the evidence pyramid (answer: meta-analysis of randomised controlled trials; randomised controlled trial, observational studies such as case–control studies, expert opinion)].

Discussion

Kuwait is a country of about 2.5 million people situated at the north of the Arabian Gulf. A strong oil-based economy has resulted in a well-established, free public healthcare service as well as a flourishing private healthcare sector. The population is heterogeneous, about half of which is indigenous, and the other half expatriates.

The sample size of public service dentists in this study represented 16.1% of the total number of dentists working in the sector. This was within the estimate made in terms of power of the study. Representation within the sample across districts did not greatly differ from the variation in the different districts. This is partly because of those who declined to participate, although staff complements at different facilities also fluctuate. Similarly, the gender ratio in the group was approximately in line with that of the profession in Kuwait, and for these reasons, the results may be considered representative for this sector of dentists.

The 80% response rate was encouraging given that response rates to questionnaire surveys amongst general practitioners have been shown to be dropping (13). Our favourable response rate could be owing to the by-hand method of distribution, in contrast to many other studies in which mailing was employed. Two limitations with regard to our questionnaire were that it was in English which made it difficult to understand for some dentists from non-English language universities, such as in Syria; also the questionnaire took time to complete making it difficult for some owing to high workloads. Another known drawback with questionnaire surveys is that they are at risk of conveying what respondents state they do, even what they believe what the interviewer wishes to hear (14). It should also be noted that the 30 of the original selection who had declined to participate might have introduced an element of underestimating the situation.

Not surprisingly, there was variation in the reported use of EBD in everyday clinical practice. Nevertheless, 92.5% claimed to be practising EBD most or at least some of the time. This was in contrast to their general lack of knowledge of the fundamentals of EBD, with only 41% obtaining a knowledge score that was above the mean score for group: for the present purposes, this was considered the cut-off point for having an acceptable knowledge of EBD. Elsewhere, studies have also attempted to assess levels of awareness and implementation of EBD by clinicians, although the possibility that the selected nature of the populations studied overestimates the level of usage of EBD amongst all dentists is real (7).

Most of our sample relied on their own judgment and other non-evidence-based sources to guide their clinical practice, including textbooks which cannot be considered sufficiently strong evidence (15). Also in this region, 13% of primary care physicians use bibliographic databases and only 6% access the internet (16).

EBM is practiced to different extents not only within countries but also between countries. Although many clinical guidelines in developed countries such as the United States, Canada, Australia, New Zealand and Europe are evidence based (17), in most developing countries, this seems not to be the case. For Kuwait, as well as other Gulf Cooperation Council (GCC) countries, the lack of information about the level of EBP being implemented has been recognised as a major issue in healthcare delivery (18). How this can be addressed is a key question. Whereas continuing professional development is an accepted method of updating knowledge, direct educational interventions, including computer-aided learning, audit and feedback, are considered to be not very effective in influencing clinical behaviours (19). Further, whilst guidelines improve dentists’ knowledge, they did not improve their clinical decision-making skills (20, 21). It would seem that an important aspect that needs research attention is the process of knowledge translation of available evidence into best practice (3).

We found a number of socio-demographic factors to be associated with the EBD knowledge score. Those who had been practicing for more than 10 years had lower knowledge scores than those who had not. This concurs with the conclusions of a systematic review on physicians’ current clinical knowledge and performance (22). Somewhat surprisingly, field of practice was not associated with EBD knowledge score. Although the reasons are unclear, it may have something to do with the identical working conditions, the structure of the public dental healthcare system and clinical guidelines in the public health sector.

Those dentists who had obtained their first degree from Asian and Arab countries (other than Kuwait) had significantly lower EBD knowledge levels compared to others. In many Asian and Arab countries, a traditional approach to dental education is still being followed, with the basic sciences taught in the early years, followed by clinical instruction in later years, and thus separating the practice of dentistry from its scientific basis (23). Learning is strongly teacher-centred, with less emphasis placed on student-centred, evidence-based learning. In many developed countries, and in recent years also at the Faculty of Dentistry, Kuwait University, the curriculum is increasingly based on problem-based learning. The curriculum consists of carefully selected and designed problems that demand from the learner an acquisition of critical knowledge, problem-solving proficiency, self-directed learning strategies and team participation skills. The process replicates the commonly used systematic approach to resolving problems or meeting challenges that are encountered in life and career (24). These include self-assessment skills to identify and remedy gaps in knowledge, information literacy and critical appraisal skills, and communication and clinical skills for working optimally with patients. Specifically, communication skills need to learn that will bring about informed patient choices and consent, in the face of a surfeit of non-scientific information available to them (4).

Several barriers to uptake of EBP have been reported in various studies, such as lack of training, time and facilities (25), and lack of time and access to resources (8). In the present study, dentists felt the most important barrier to be the lack of an internet connection at the workplace, followed by lack of access to international dental journals. In the final analysis, to the same extent that evidence is needed to inform clinical decision-making, the application by mentors of approaches to learning that are well-founded is crucial, especially because it can be asserted that the outcome of care provided by dental graduates is related to their education. However, this relationship is at best indirect, and to test it is difficult (1, 26). The potential benefits of a smaller dental healthcare setting such as we have in Kuwait, in implementing change, and managing it sustainably, are clear to see. What remains is the appropriate research that needs to precede any purposeful move towards EBP.

Conclusions

The overall awareness of EBD amongst dentists in Kuwait was low, even though more than half of them reported that they generally practise it. On the basis of their actual knowledge of EBD, the claim about practice of EBD may be a gross overestimate, which needs addressing. Although the evidence that EBD works is, in an absolute sense, limited, it offers an opportunity for improvement in oral health and oral health-related quality of life of patients and communities by integrating evidence with traditional caring skills. Any effective move towards its achievement will need the support of all the stakeholders, that is, the profession, both academic and practitioners, the authorities and funders, and society.

Acknowledgements

We are grateful to Dr Prem Sharma, Health Sciences Centre, Kuwait University, for his advice and assistance in the statistical analyses, and to Dr Essam Zaater, Ministry of Health, for providing data on the numbers of dentists working in various facilities.

Appendix

Algorithm used to compute an EBD knowledge score from specific questions (no. refers to the question number in the questionnaire)

No.QuestionScore
10EBM pyramid4
13A P-value1
13BRelative risk1
13CSensitivity1
13DMeta-analysis1
13EOdds ratio1
13FPublication bias1
13GConfidence interval1
18EBM is a practice that ignores clinical experience2
19EBD is based on expert opinions2
20EBD is about making accurate diagnoses and selection of optimal treatments for individual patients2
21Based on the evidence, amalgam should be banned from practice2
22Based on the evidence, antibiotics should be prescribed for a localised swelling related to a decayed tooth2
Total21

Ancillary