Knowledge and Practice of ICDAS and ICCMS in Young Children: A Cross-sectional Study among Final-year Dental Students in Malaysia

INTRODUCTION

Dental caries is an infectious disease that results in localized destruction and dissolution of the calcified tissue.¹ This happens through the interaction of bacteria mainly Streptococcus mutans, and the sugar from food, through its byproducts on tooth enamel resulting in cavitation of the teeth.^2,3 This disease has proven to be an impending issue for worldwide public health.⁴ According to the American Academy of Paediatric Dentistry (AAPD), Early Childhood Caries (ECC) is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.² Although this condition can be prevented with proper oral hygiene, dietary measures, and the use of fluoride; surprisingly, it is still one of the most common chronic diseases among young children, outranking some other diseases such as asthma or hay fever.^5,6

In children, dental caries can drastically affect their quality of life because of the long-term ramifications arising from caries such as severe pain, chewing difficulty, poor speech and articulation, abscesses, low self-esteem, malnutrition, and increased risk for future caries.⁷ Being highly prevalent in both developing and industrialized countries, this poses a serious public health concern. The rates of caries in developing nations such as Africa and Southeast Asia seem to be approaching worrying proportions at around 44–82.5%.³ The first Malaysian national epidemiological survey done on 5-year-old pre-school children in 1995 shows that almost 9 out of 10 children had tooth decay. Ten years from then in the National Oral Health Survey of Preschool Children 2005 (NOHPS 2005), an improvement was present but quite insignificant in terms of dental caries status among the 5-year-old children. Standing at a staggering percentage of 76.2%, the caries level in deciduous teeth stood at a mean dmft of 5.6 with highly unmet treatment needs.⁸ The awareness, understanding, and early risk assessment for these children facilitates the identification of parent-infant groups with high risk for caries and would benefit significantly from early preventive intervention.⁷ Despite the urgency and importance of early risk assessment, only a limited workforce is available to address their oral health needs.

Pediatric dentistry has been considered as the most needed but neglected area of all the services performed by dental practitioners. There is a lack of knowledge in the preventive aspects of caries.⁹ There needs to be a more thorough understanding of the progression of caries and the intervention or management of caries in children. Dental practitioners are expected to diagnose and manage effectively childhood dental diseases that are within the knowledge and skills acquired during dental education.¹⁰ For this to become a reality, dental practitioners need to be well versed in this field of oral healthcare and thereby enable more children to have access to dental services. Given the importance of such knowledge in treatment planning, dental students need to more aware of pediatric oral health to be able to recognize and classify them accordingly, hence be able to diagnose and instigate prevention or intervention methods.

The International Caries Detection and Assessment System (ICDAS) and International Caries Classification and Management System (ICCMS) provide a comprehensive list of criteria using a standardized system based on clinical evidence for early and late stages of caries. In a systematic approach, the risk factors would be assessed, a diagnosis and prognosis formed, and informed decision-making in the comprehensive management of the carious teeth would be carried out.^11,12 International Caries Detection and Assessment System is a globally adopted method for classifying different stages of dental caries and the activity status of lesions which can be integrated into the ICCMS(TM).¹² The ICCMS(TM) enables dentists to integrate the patients’ dental information including caries risk status, for the purpose of formulating a treatment plan, managing, and reviewing dental caries.¹² Despite the availability of these caries risk detection tools, it is unsure if this was taught in the dental schools and the knowledge of the students was appropriately measured. This study aimed to evaluate the association of sex, type of institution, and satisfaction of educational activities with dental students’ knowledge of ICDAS and ICCMS in young children.

MATERIALS AND METHODS

RESULTS

A total of 616 final-year pre-doctoral dental students were identified across accredited dental schools all over Malaysia. A total of 440 questionnaires were received from 5 private and 6 public schools. The respondents’ age ranged between 22 years and 35 years old out of which 384 respondents (87.3%) were 23 years and 24 years old. There was a total of 312 (70.9%) female respondents and 128 (28.6%) male respondents and two did not indicate sex. For the institution type, there was an almost equal distribution of respondents with 231 (52.5%) from the private institution and 209 (47.5%) from the government institution (Table 1). Two out of 13 dental institutions did not participate in the study. Overall satisfaction level showed that all the respondents felt adequate, satisfied, and very satisfied with the educational activities conducted (Table 2). Most students agreed or strongly agreed that they were aware of ICDAS, had adequate ICDAS training, were satisfied with their ICDAS training, were confident in using the ICDAS, and were able to communicate about ICDAS. The ICDAS items that most students felt they were unsure with the satisfaction of training and confidence in using ICDAS (Table 3).

Most students reported that they were unsure about the ICCMS. Around 27.5–30.7% of the students disagree or strongly disagree with the adequacy of training received, unsatisfied with the training given to them in school, unable to understand the ICCMS codes and effectively communicate using ICCMS, and did not have the confidence in formulating a treatment plan based on ICCMS (Table 4). Male students had statistically significantly higher scores than female students on satisfaction with the pediatric dentistry lectures given during their preclinical studies and satisfaction with preparation for treating pediatric patients (p < 0.05) (Table 5). Females were more satisfied with the ICDAS and ICCMS training in school as compared to males. The mean score for males on the awareness of ICDAS, training received in ICDAS, training satisfaction, confidence in classifying caries, and communicate effectively with ICDAS were lower in general compared to females. The awareness of ICCMS for females was highest among the other ICCMS items. At a mean score of 3.0, female respondents felt unsure of the adequacy of training received, a satisfaction of training received, understanding of codes corresponding to the lesion, communicating effectively using ICCMS, making a treatment plan, and treating a patient based on ICCMS (Table 6).

The satisfaction level toward the number of clinical hours allocated to treat pediatric patients was statistically significantly higher among students from private institutions than from public institutions (p < 0.05). Students from public institutions, however, felt more prepared to treat patients independently upon graduation than students from the private institution (Table 7). No difference was observed between the private and public institutions on the satisfaction based on the number of pediatric patients allocated and pediatric dentistry lectures were given during preclinical studies (p %3E; 0.05). The students’ knowledge did not seem to be affected by the type of institution and the knowledge on ICDAS or ICCMS. There was a unanimous uncertainty of the awareness of what ICCMS is, satisfaction with the training received in school, having confidence in making a treatment plan, and treating a patient confidently using the ICCMS (Table 8). No correlation was observed between the satisfaction level of educational activities and knowledge of dental students in ICDAS, however, a high correlation was observed between the satisfaction level of educational activities and ICCMS knowledge (p < 0.05). The number of pediatric patients allocated to dental students and their preparedness to treat upon graduation had a strong correlation (Table 9).

DISCUSSION

This study was aimed to measure the association that sex, type of institution, and satisfaction of education activities had with dental students’ knowledge of ICDAS and ICCMS on young children’s (0–6) oral health. The findings showed that male dental students were more satisfied with the education activities than their female counterparts and were more prepared to treat pediatric patients independently when they graduate. This was in accordance with a previous study by Gilmour et al.¹⁴ However, these findings were in contrast to what has been found in some literatures where females are usually more satisfied.¹⁵ The differences in country, cultural background, and the setting of this study done may have attributed to this alongside the year where this study was conducted. There seemed to be no disparity in the knowledge of ICDAS and ICCMS among Malaysian dental students by sex or type of institution. Previous studies conducted among the dental students of other countries; which aimed to explore their ability to examine dental caries using the ICDAS system also showed similar results.^16,17 Even though ICDAS and ICCMS have only recently been developed in the last decade, after many workshops and meetings between many experts to refine these diagnostic criteria and its management, the implementation of this framework and accessibility of ICDAS and ICCMS could be widespread enough to negate any disparity.^18,19

It is interesting to note that the students have higher knowledge in ICDAS in comparison to ICCMS. This might be due to ICCMS not being the only system available for promoting the staging of caries, risk assessment, and management.¹¹ Some schools may also be utilizing other systems to treat and manage their patients. There is the possibility of a national movement steering and comprehensively setting into motion of ICDAS within the context of the local curriculum and oral healthcare delivery arrangements, an initiative 5 years ago, launched by the Malaysian Dental Dean’s Council (MDDC) in October 2013 on the integration of ICDAS into the dental school curricula.²⁰ Most schools would then have been actively educating and training their students in recognizing and diagnosing caries using ICDAS but may not necessarily have taught about ICCMS. However, the intervention using ICCMS, to ensure that caries does not progress further, is as paramount as ICDAS. Only a handful of students have heard of what ICCMS is, where only a few knew what it entails.

Dental students need to be well equipped in diagnosing and managing caries. The ICDAS e-learning program available on the Internet, developed by the ICDAS Foundation (distribution from Smile-On Limited), can be an effective tool in this regard.²¹ Through this study, we also recommend for schools to educate, train and place emphasis on ICCMS alongside ICDAS in their study curricula. This would enable dental students to be able to properly diagnose and subsequently formulate a thorough treatment plan for their pediatric patients. We have attempted to report all the contents appropriate for cross-sectional study and have followed the reporting guidelines as indicated in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.²² This study evaluated the knowledge of ICDAS and ICCMS only on final year pre-doctoral students in Malaysian dental schools and this limits the possibilities of generalizing the outcomes to dental students in other countries. In addition, the respondents were grouped within a generalized category by private and public schools. It is not clear if the dental practitioners use any of the caries detection and management system in their practice and future studies could be conducted to assess and compare the dental practitioner’s knowledge in the area of ICDAS and ICCMS.

CONCLUSION

Male dental students felt more satisfied with pediatric lectures conducted during preclinical years and were more prepared to treat patients independently upon graduation. Sex and type of institution do not play a role in the ICDAS and ICCMS knowledge of dental students. Dental students were more knowledgeable in ICDAS compared to ICCMS. The number of patients treated during their clinical sessions and their preparedness to treat patients was independently related to their knowledge in ICCMS.

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