The results of our study confirmed the disagreement regarding the oral health-related preventive recommendations among pediatricians. There were significant differences between the recommended age for the start of tooth-brushing, the use of toothpaste and prescription of vitamin D with or without fluoride. These results refer to the professional recommendations. Additionally, the study findings showed a large variability regarding the recommended age for the start of tooth-brushing and the use of toothpaste. The majority of pediatricians did not use the specified recommendations "with the 1st tooth" or "after 4th birthday" of the professional associations. The guidelines of the DGKJ and the DAKJ suggest the prescription of fluoride supplements immediately after birth and starting the use of toothpaste by 4 years of age if the child can spit it out
[2, 5]. The DGZMK prefers the start of tooth-brushing with fluoride toothpaste when the first tooth erupts instead of using fluoride supplements
[1, 5]. Between these guidelines are 3 years of disagreement, and only a small group of pediatricians adhere to them. The majority of pediatricians who responded to this questionnaire used a mix of both current guidelines with a result of no use or possible overdose of fluoride in children.
A comparison of our results with nationally and internationally conducted surveys among pediatricians showed that there were commonalities as well as differences
One commonality was the recommended age for the first dental visit. Most pediatricians refer children to the dentist at the age of 3
[12–18]. The majority of respondents from our study recommended the first dental visit after the 2nd (63.0%) or 3rd and 4th (15.0%) birthday. The National German Health Interview and Examination Survey for Children and Adolescents showed that 92.3% of children had their first dental visit within the first 3 years of life and confirm our results
. Internationally, there is a demand for early establishment of regular dental care by age one
. In most cases, parents do not take the initiative to make sure that their children receive regular dental care in first years of life. Irregular dental visits are common, and toothache is the major driving factor for seeking dental care
. Until this process is reevaluated in the minds of parents, pediatricians and dentists, the pediatrician will regard her/himself as being responsible for oral health care in a child’s first years of life.
In other countries, there is agreement between the societies of pediatricians and dentists that tooth-brushing with fluoride toothpaste has to begin with the eruption of the first tooth
[12, 13, 20, 21]. A survey among pediatricians in Connecticut showed that most of them recommended this starting point
. In contrast, the majority of our responders recommended the start of tooth-brushing and the use of toothpaste after the 1st birthday. Pediatricians and dentists are in agreement that young children swallow the majority of toothpaste until they can spit out and that it is necessary to limit the consumption of toothpaste with dose recommendations
[1–5, 13, 20–22]. Additionally, parents should assist and supervise tooth-brushing
[3–5, 21, 22]. The AAPD recommends that children less than 2 years of age should use a smear layer of fluoride toothpaste (≥1000 ppm) twice a day, and children up to 5 years of age should use a pea-sized amount
. The EAPD recommendations suggest that children use a pea-sized amount of fluoride toothpaste twice daily, with the difference that children less than 2 years of age should brush with 500 ppm fluoride toothpaste, and children up to 6 years of age should brush with 1000 ppm fluoride toothpaste due to the risk of dental fluorosis (DF)
. In Germany, the regulations go a step further, suggesting that children up to the age of 6 should use 500 ppm fluoride toothpaste to minimize the cumulative effects of other fluoride sources
In contrast, only 20.9% of our responders advised parents regarding the dosage of fluoride toothpaste and 9.0% regarding the frequency of tooth-brushing. Additionally, 45.9% of pediatricians recommended the simultaneous use of fluoride supplements and fluoride toothpaste in first three years without information about other fluoride sources or water fluoride levels. A questionnaire among German dentists showed similar results
. Most of the dentists (92.0%) recommended tooth-brushing with fluoride toothpaste, but one fifth of them also prescribed fluoride supplements, and 58% of the respondents did not know the dose limit of 0.05 milligrams of fluoride per kilogram body weight for the development of DF
Children younger than 3 years are considered to be at risk for DF of permanent incisors and first molars
[1, 2, 5, 21, 22, 24]. In Germany, the prevalence of DF (mild form) in 7-year-old children is approximately 10.1%
. The increase in the number of sources of fluoride exposure, such as water, beverages, food, salt, fluoride supplements and dental products, could lead to an overdose in this sensitive phase of tooth development
[1, 2, 5, 21, 22, 24]. Reviews had found that prolonged use of fluoride supplements during tooth development increases the risk of developing DF
[22, 25]. If tooth-brushing with fluoride toothpaste started later than 12 months of age or the fluoride level of toothpaste was < 1000 ppm, a statistically significant reduction in DF was found
Both guideline recommendations of the DAKJ and the DGZMK cannot exclude the risk of developing DF. Studies about the effectiveness in the primary dentition of fluoride supplements and fluoride toothpaste containing <1000 ppm are weak and are difficult to perform for ethical reasons, so discussions between both societies will be continued
[1–5, 21, 22, 25].
Healthcare professionals want to promote healthy development of children, and guidelines should encourage them to treat and inform patients to the best of the current knowledge and belief. For the prevention of ECC as a public health problem, adverse effects of fluoride use such as DF with purely aesthetic problems should remain in the background. So that an agreement can be reached between pediatricians and dentists, all healthcare professionals should respect the opinions of other professionals and pay attention to daily fluoride ingestion, especially in the first 3 years, and use either fluoride tablets or fluoride toothpaste for children with no increased risk of caries
[1–5, 21, 22, 24].
As a secondary objective of this study, we wanted to examine whether there were differences between pediatricians in terms of oral health practices when taking their characteristics into account. This study found that the preventive recommendations given were irrespective of the gender and age of the pediatrician but tended to differ between pediatricians practicing in rural and urban areas. Pediatricians practicing in urban areas were more progressive and recommended vitamin D without fluoride and the use of toothpaste much earlier than their colleagues from rural areas. The preventive recommendations of employees and practice owners were significantly different. The majority of practice owners recommended commencement of tooth-brushing with the first tooth and the use of fluoride supplements. The recommendations to use toothpaste as well as the first dental visit were made in later years. This reflects recommendations that have been made for decades
. Employees’ university studies were usually relatively recent, and their recommendations were likely based on recent international publications and guidelines.
Actually, oral health plays a minor role in the medical curriculum, and several studies have revealed that pediatricians’ knowledge regarding child oral health is insufficient
To win the battle against ECC and to improve the oral health of our children, pediatricians as well as dentists are challenged to incorporate infant oral health care into their practices
[6, 7, 9–11, 20, 25, 26]. Training programs should encourage these healthcare professionals to assess caries risk, to perform a knee-to-knee exam and to counsel parents about oral hygiene, fluoride, diet (especially with regard to sugared and acidic drinks) and prevention of early transference of bacteria from parents to child
[10, 11, 20, 25, 26].
Until now, there have been no special oral health training programs for pediatricians in Germany. Internationally, such training programs already exist
[27, 28]. A study showed that after the implementation of a caries prevention program in the medical education curriculum, physicians were able to diagnose dental caries, and it became the 11th most common diagnosis made in the clinic
. Infant oral health training courses for primary care providers could be the basis for successful collaborations among pediatricians and dentists.
There are a few limitations of this study. This was a regional survey conducted in one of the federal states of Germany, Thuringia, so the results are not representative of the rest of Germany. For the evaluation and generalizability of our results, we compared them with national and international studies of pediatricians that achieved similar results and confirmed our study findings
Another limitation of this study was the response rate. On the one hand, the content of a study called "Use of fluorides and oral health related recommendations in 0- to 3-year-old children" is a tiresome problem due to years of dispute, and on the other hand, it is an internationally increasing problem to achieve high return rates
[29–35]. The Commonwealth Fund conducted an international survey of doctors from 7 countries and achieved a participation rate in Germany of 18.1% in 2006 and 31% in 2008
[29, 30]. To improve the response rate of our survey, pediatricians had the ability to return their responses by fax, email or in postage-paid envelopes, and non-respondents received a reminder. In this way, we were able to achieve a response rate of 52.0%. Typical return rates for postal surveys in Germany are between 10 and 60 percent
. Higher rates could be achieved with more effort and higher costs, but the cost-benefit ratio was not justified with this study. Of course, a response rate of 52.0% means that approximately 48.0% of the practitioners did not respond and that there could be potential bias. A review of the literature showed that low response rates to physician surveys are common and do not imply non-response bias
. A survey in the USA showed that physicians have more homogeneous characteristics than other professional groups and that non-response bias is likely to be less important
. A meta-analysis of the impact of non-response rates on non-response bias of 566 standard estimates from 44 studies showed that non-response rates could explain 8 to 19 percent of the variation in different estimates of the non-response bias
. Another study examined a set of 30 studies estimating the non-response bias of descriptive statistics and found that the non-response rate is a poor predictor of bias magnitude
. In this study, no analysis of the group of non-responders was made due to cost and effort. A comparison with other studies of pediatricians and a review of the literature about non-response rates and non-response bias has shown that no other results could be reasonably expected
To our knowledge, this was the first survey examining the guidelines used by Thuringian pediatricians in daily practice. The results revealed that uniform guidelines have to be developed containing exact information and instructions about when and what should be done, prescribed or recommended, and how it should be done. DF is an increasing aesthetic problem, but the consequences of ECC affect general and oral health as well as quality of life in children
In summary, it can be stated that all healthcare professionals should be trained in infant oral health care to fulfill the requirement of the Global Caries Initiative of the FDI World Dental Federation, which places primary oral health care within maternal and child health programs using multi-sectoral and collaborative approaches