This study highlights the gaps in oral health-related interdisciplinary and pointed out the influencing factors among four groups of health professionals in Saudi Arabia. Our results showed that from the predisposing factors, the type of specialty (Pediatricians or Physicians) and years of experience (more than 3 years) were associated with higher odds of referral practices. From the facilitating factors, source of oral health knowledge (MOH and formal education) was significantly associated with greater odds of all interdisciplinary practices. While participants with good oral health knowledge were more likely to respond to patients’ oral health questions as well as have more referral practices. However, attending OHE training and participants’ attitudes were less likely to influence oral health-related interdisciplinary practices.
Participants in the current study demonstrated fair oral health knowledge, which was significantly different among the health professionals with physicians attaining the highest knowledge scores while the nurses had the lowest knowledge scores. Poor oral health knowledge among nurses and better knowledge among physicians have also been reported in other studies [11,12,13,14, 23, 25, 26, 28]. The low level of oral health knowledge observed among health professional has been found to be related to limited integration of oral health content in under-graduate training programs [28, 29], as well as the lack of protocols and regulations to meet current standards of integrated care [28, 30]. Policy makers in higher education may consider oral health integration into medical and nursing curricula, and that some sessions be delivered along with dental students.
Almost all participants in the current study were unaware about the clinical presentations of dental caries and periodontitis which is a remarkable finding. However, low competency level for identifying dental caries and oral pathology has also been reported earlier [23, 31]. In our study we had strict scoring criteria for the knowledge section. For example, the question about the clinical presentations of dental caries included white spot lesions, staining as well as cavitation. Only those who were able to choose the whole set of correct answers were considered knowledgeable about the clinical manifestations. The connection between oral and general health is well and undeniably established ; physicians, dentists and nurses can be encountered by medical conditions that aggravate oral problems and vice versa . For instance, diabetes and periodontal disease are mutually dependent since both negatively affect each other and share a common pathophysiological pathway . In a country (KSA) where the prevalence of uncontrolled type II diabetes is among the highest in the world (77.7%) , oral health knowledge and dentalcare is, therefore, essential. In the same way early childhood caries (ECC) is a prevalent oral health problem with lifelong consequences that affect the child’s health and wellbeing , with financial burden on parents as it often/frequently necessitates the aid of general anesthesia . Suboptimal knowledge about early signs of dental caries amongst health care providers may cause delayed referrals and place children at high risk of worsening health and chronic illness [36, 37]. Therefore, it is essential to educate healthcare providers about the early signs and clinical presentations of oral diseases.
The observed attitudes towards oral health and oral health-related interdisciplinary practices were also average in the current study with ENT specialists showing the most positive attitudes while the most unfavorable attitudes were among the nurses which contradicts the findings reported from Riyadh, Saudi Arabia  and from the USA . The importance of nurses in maintaining the dental health and well-being of hospitalized patients cannot be overstated [23, 24]; with this in mind, nurses must be willing to provide adequate oral care in their setting. Some of the observed participants’ negative attitudes were concerns about time allocation as well as financial compensations. ENT specialists, for instance, have a scheduled number of patients per day and they have the freedom to allocate the time for each patient. This is not the case for nurses who have no control on the flow of patients or the time, thus it is understandable that another task (such as oral healthcare) would be reluctantly accepted. The first step in changing attitudes is by creating a positive social change which could be achieved by improving the undergraduate curricula, providing training and workshops, presence of a policy for oral care in workplace and equipping the health care setup. Perceived organizational support, or employee impressions of how much their employer values their contributions and cares about their well-being, can influence work attitudes and readiness [38, 39].
Provision of OHE was the most common reported interdisciplinary practice followed by responding to a patient’s question about oral health condition or problem and the least practiced were conducting OHS and referring a patient to a dentist. Referral of patients requires the knowledge and understanding of referral loops within one’s institution which in turn requires extra administrative duties. In the same context, conducting OHS requires confidence which is usually based on sound knowledge (which was not the case in the current study). Studies conducted worldwide among physicians and other healthcare providers have found that education, risk assessment, and referral practices are relatively uncommon [29, 31, 32, 38]. The current study found that the rates at which providers reported engaging in transdisciplinary activities varied by provider type. Pediatricians were twice as likely as family physicians to provide OHE and refer patients to dentists, which is consistent with a previous study that found in terms of general dental knowledge and preventive oral health counseling, pediatricians were better informed than family physicians . Early dental visit is one of the foundations for promoting the oral health of a child and in the prevention of ECC, according to the American Academy of Pediatric Dentistry . Physicians and nurses can be patients' first exposure to health-care system . Children are exposed more to pediatricians and family physicians at earlier age than dentists [38, 40], and they can perform OHS seven times more frequently than dentists . It is important for pediatricians and general practitioners to understand their role in children's oral health, prompt management and referral to dental specialty [23, 43]. If equipped with the essential knowledge, pediatricians can play a major role in educating parents about children’s dental health, caries preventive measures as such help in establishing early dental homes.
It was observed that those with more than 10 years of experience had greater odds of referral practices, similarly those with good knowledge scores were more likely to respond to patients as well as have better referral practices. These findings are in line with many studies nationally and internationally [26, 29,30,31,32]. A recent multicenter study involving dental pediatricians from three different countries (United States of America, Greece, and Saudi Arabia) found that knowledge was proportionally associated with experience . Experience was thought to be the reason for the discrepancies seen in oral health-related knowledge and interdisciplinary practices namely referrals . Experienced health professionals are expected to have more frequent exposure to cases related to oral health as well as to being more informed about loops of referrals within their institutions .
Participants who relied on their formal education or on the MOH as a source of oral health knowledge had greater odds of involvement in oral health-related interdisciplinary practices. The suboptimal knowledge, attitudes and practices can be mainly due to lack of organizational support both in the educational system as well as in practice. Gaps in the medical and nursing oral health-related curricula have been acknowledged in many studies [7,8,9,10, 28, 31]. It was also suggested that including oral health training in the medical staff curriculum could improve oral health knowledge and increase confidence in performing OHS and caries risk assessment . The current study emphasizes the role of organizational support on interdisciplinary practices as well as on the factors that influence them.
Surprisingly, attending oral health training as part of professional development did not influence participants’ practices. Contradicting our findings some studies reported that oral health-trained physicians are more likely to provide more relevant and thorough advice to patients with oral problems, as well as more comprehensive emergency care [45,46,47]. Health care providers need to understand their role in the integration of oral health and the need to receive appropriate oral healthcare training. Integration of oral health into the practices of health-care providers can improve access to oral health treatment for the disadvantaged individuals. Workshops, seminars, distance learning, and in-service training with flexible timings and delivery can be some of the OHE delivery methods . The Saudi Commission for Health Specialties regulates continuous medical education (CME) in Saudi Arabia and mandates all healthcare practitioners to acquire a certain number of CME hours each year to maintain their professional licensing . However, this licensing body does not consider CME hours taken outside the scope of someone’s practice. We recommend the need for CME training courses to meet the learning needs for oral health especially those related to disease identification, risk assessment and prompt referrals.
In the current study participants’ interdisciplinary practices were not related to their knowledge, and attitude. The majority of the sample had an average knowledge and attitude in line with reports from Riyadh . It is expected that the higher the knowledge or awareness about a condition, the more positive the attitudes about it the more likely people will be engaged into protective actions against it . Participants in the current study had an average level of knowledge with essential/central/fundamental gaps in areas related to the clinical presentations of dental diseases as well as its prevention, which can explain why participants’ knowledge and attitudes did not have a greater influence on their interdisciplinary practices. Similar observations were also reported by a recent study from Eritrea as nurses’ attitudes did not affect their oral healthcare practices . In addition to the macro (policies and regulations) and meso (financial compensation and manpower) level factors mentioned earlier, the daily practice of dentists and other healthcare providers are separated in KSA. In both private and public sectors dentists work in separate clinics and the various specialties are assembled in departments, for example ENT department, pediatric department etc. This may be one of the reasons that further widen the gap between dental and other healthcare providers.
There are some limitations that we would like to acknowledge. First the cross-sectional data can be interpreted only as an association rather than a cause–effect relationship. Second, the data were self-reported, so over or under-reporting may have occurred. Thirdly, there was no random sampling in the current study, which may raise the potential for selection bias in this study. Lastly, we did not look at the differences in participants’ undergraduate curricula. Despite the potential limitations mentioned, the large sample size and the validated instrument used, we believe that our findings have implications for interdisciplinary and integrated care providers worldwide as well as pave the way for further research into the effectiveness of possible solutions and interventions.