RESEARCH ARTICLE Open Access
Den al sealan knowledge, opinion, alues and
p ac ice o Spanish den is s
Lau a San Ma in
1,2,3*
, An onio Cas año
4
, Manuel B a o
5
, Ma y Ta a es
6,7
, Richa d Niede man
8
and Eyi ope O Ogunbodede
9
Abs ac
Backg ound: Mul iple guidelines and sys ema ic e iews ecommend sealan use o educe ca ies isk. Ye , mul iple
epo s also indica e ha sealan s a e signi ican ly unde u ilized. This s udy examined he knowledge, opinions,
alues, and p ac ice (KOVP) o den is s conce ning sealan use in he sou hwes egion o Andalusia, Spain. This is a
p elude o he gene a ion o a egional plan o imp o ing child en’s o al heal h in Andalusia.
Me hods: The su ey’s a ge popula ion was den is s wo king in wes e n Andalusia, equally dis ibu ed in he
p o inces o Se ille, Cadiz, and Huel a (N=2,047). A con enience sample o mee ing pa icipan s and mee ing
pa icipan email lis s (N=400) we e solici ed om he annual cou se on Communi y and Pedia ic Den is y. This
cou se is equi ed o all public heal h sec o den is s, and is open o all p i a e sec o den is s. In o ma ion on he
den is ’s KOVP o sealan s was collec ed using ou -pa ques ionnai e wi h 31, 5-poin Like -scaled ques ions.
Resul s: The su ey popula ion demog aphics included 190 men (48%) and 206 women (52%) wi h an a e age
clinical expe ience o 10.6 (± 8.4) yea s and 9.3 (± 7.5) yea s, espec i ely. A signi ican sex di e ence was obse ed
in he dis ibu ion o place o wo k (u ban/subu b) (p=0.001), bu no sex di e ences be ween wo king sec o
(public/p i a e). The mean ± SD alues o each o he ou KOVP sec ions o pi and issu e sealan s we e:
knowledge = 3.57 ± 0.47; opinion = 2.48 ± 0.47; alue = 2.74 ± 0.52; and p ac ice = 3.48 ± 0.50. No sex di e ences
we e ound in KOVP (all p >0.4). Independen o sex: knowledge s a is ically di e ed by yea s o expe ience and
place o wo k; opinion s a is ically di e ed by yea s o expe ience and sec o ; and p ac ice s a is ically di e ed by
yea s o expe ience and sec o . Less expe ienced den is s ended o ha e sligh ly highe sco es (~0.25 on a Like
1–5 scale). S a is ically signi ican co ela ions we e ound be ween knowledge and p ac ice ( =0.44, p=0.00) and
be ween opinion and alue ( =0.35, p=0.00).
Conclusions: The esul s sugges ha , simila o o he coun ies, Andalusian den is s know ha sealan s a e
e ec i e, ha e neu al o posi i e a i udes owa d sealan s; hough, based on epidemiological s udies, unde use
sealan s. The e o e, me hods o he han classical beha io change (eg: inancial o legal mechanisms) will be
equi ed o change p ac ice pa e ns aimed a imp o ing child en's o al heal h.
Keywo ds: Fissu e sealan s, Den al, P e en ion, Child en, O al heal h
* Co espondence: [email p o ec ed]
1
School o Den is y, Uni e si y o Se ille, A icena s/n, Se ille, Spain
2
Fo sy h Ins i u e, Camb idge, MA, USA
Full lis o au ho in o ma ion is a ailable a he end o he a icle
© 2013 San Ma in e al.; licensee BioMed Cen al L d. This is an Open Access a icle dis ibu ed unde he e ms o he
C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/2.0), which pe mi s un es ic ed use,
dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed.
San Ma in e al. BMC O al Heal h 2013, 13:12
h p://www.biomedcen al.com/1472-6831/13/12
Backg ound
Den al ca ies is among he mos common o p e en able
childhood in ec ions [1], and me hods a e cu en ly a ail-
able o cos e ec i ely educe ca ies [2]. The mos e ec-
i e me hod o educe occlusal ca ies a e pi and issu e
sealan s, and o e he las ou yea s mo e han 11
guidelines and sys ema ic e iews ha e ecommended pi
and issu e sealan use o a - isk popula ions [3-13].
Howe e , s udies om U.S. [14-16], G eece [17], Sweden
[18], and Sco land [19,20] all indica e ha sealan s a e
unde u ilized.
In Spain, ecen su eys indica e a 56% ca ies p e alence
among 15–16 yea olds, while only 17% ha e sealan s
[21,22]. O he Spanish s udies demons a e ha occlusal
sealan s can educe bo h occlusal and smoo h su ace
decay by 87% and 68%, espec i ely, o e a wo yea
pe iod [23]. O e a nine yea pe iod sealan s can educe
occlusal decay by 65% [24].
Thus he e a e e ec i e me hods o ca ies p e en ion,
bu hey a e unde u ilized. The heo e ical ame o be-
ha io change is an assessmen o knowledge and a i udes
a ec ing p ac ice. Howe e , nei he heo ies o beha io
change no knowledge no a i udes p edic clinical p ac-
ice [25]. Ins ead, bo h indica e ha alues a e be e
p edic o s [20,26]. The e o e, we examined knowledge
combined wi h opinions and alues, as a i s s ep owa d
ini ia ing comp ehensi e ca ies p e en ion p og am in
Spain. Mo e pa icula ly we assessed den is s in he wes -
e n p o ince o Andalusia ega ding o he use o pi and
issu e sealan s.
Me hods
Li e a u e sea ch
A comp ehensi e sea ch o me a-analysis and sys ema ic
e iews on pi and issu e sealan s was conduc ed by he
au ho s using he Pubmed Da abase (h p://www.ncbi.
nlm.nih.go ) (Tables 1 and 2).
Su ey gene a ion
In o ma ion om he s udies iden i ied in he MEDLINE
sea ches we e used o gene a e he 31 su ey ques ions in
ou g oups: knowledge, opinion, alues and p ac ice. Each
ques ion was e iewed o pe inence and cla i y by 8 ull
and pa - ime acul y who each p e en ion (N=5),
pedia ic den is y (N=2), o a e p og am di ec o s o
communi y den is y (N=1) in Andalusia. A Like 1–5
scale su ey (1 = s ongly disag ee; 5 = s ongly ag ee),
and na a i e commen a y we e used o e alua e he su -
ey. The ques ions we e edi ed as sugges ed by he ini ial
su ey panel. The su ey was hen sen o 20 den is s
wice, one week apa , o de e mine es / e es alidi y.
Su ey me hod
The su ey’s a ge popula ion was den is s wo king in 3
o he 4 wes e n p o inces o Andalusia: Se ille, Cadiz,
and Huel a (N=2,047). Raoso was used o gene a e a
powe calcula ion (h p://www. aoso .com/samplesize.
h ml). Fo a 5% ma gin o e o , a 95% con idence le el,
a popula ion o 2,047, and a esponse dis ibu ion o
50%, he minimum ecommended su ey size is 324.
We solici ed a con enience sample o pa icipan s om
he annual Communi y and Pedia ic Den is y cou se.
This is a equi ed cou se o all public heal h sec o
den is s, and is open o all p i a e sec o den is s. I is
a ended by den is s wi h an in e es in pedia ic den is y.
Di ec solici a ion o mee ing pa icipan s and solici a ion
om pa icipan email lis s we e used o ec ui a con eni-
ence sample o 400 den is s, equally dis ibu ed be ween
he h ee p o inces. Mee ing pa icipan s we e su eyed a
he mee ing, in pe son, and accoun ed o app oxima ely
46% o he esponses. The mee ing pa icipan s p o ided
email add esses du ing egis a ion. F om his email lis
we selec ed indi iduals who did no espond in pe son.
F om his email lis we iden i ied indi iduals om h ee
geog aphic egions. We hen emailed he iden i ied num-
be o indi iduals in each egion asking hem i hey would
comple e he su ey. We i e a i ely con inued his un il
we illed he quo a de e mined by he powe calcula ion.
The o al numbe o p o essionals a ending he mee ing
who esponded o ou su ey was 184. The emaining 216
pa icipan s we e ec ui ed by email.
Table 1 To iden i y he cu en bes e idence on pi and issu e sealan s we que ied MEDLINE using he ollowing
sea ch s a egy
S ep Sea ch Found
1 (den al sealan s) OR ( oo h sealan s) OR ( issu e sealan s) OR (pi and issu e sealan s) 3058
2 (me a-analysis) OR (sys ema ic e iew) 1,732,591
3 1 AND 2 348
4 2008[PDa ]:2012[PDa ] 3,756,585
5 3 AND 4 68
Rele an = 11
Sea ch #1 was limi ed o sys ema ic e iews o human andomized con olled ials. The i les and abs ac s we e examined o iden i y sys ema ic e iews wi h
me a-analysis ele an o ca ies p e en ion.
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Demog aphics
Su ey esponden s we e iden i ied by 4 me ics: sex, yea s
in p ac ice (≤3, 4–15, ≥16), p ac ice loca ion (u ban, sub-
u ban), and ype o p ac ice (public, p i a e, bo h).
S a is ical analysis
Fo each o he 31 su ey i ems and o each o he ou
assessmen domains (knowledge, opinions, alues, and
p ac ice) a equency dis ibu ion o he Like scale was
de e mined as well as he mean. These we e e alua ed
indi idually using he Wilcoxon ma ched-pai s signed-
anks es , he F iedman nonpa ame ic epea ed measu es
ANOVA, o Spea man’sco ela ion.
Resul s
Su ey
Tes - e es alidi y was de e mined wi h 20 den is s e es ed
a an in e al o one week (C onbach´s alpha =0.872). The
equency dis ibu ion o he 31 ques ions in he ou
sec ions - knowledge, alues, opinion, and p ac ice - is
p esen ed in Table 3. The mean ± sd sco es o he indi-
idual ques ions anged om 1.53 ± 0.82 o 4.29 + 0.90
wi h an o e all o 3.15±0.31. All he den is s who a ended
he cou se illed ou ou su ey. Ou esponse a e om
he emails was 76%.
Demog aphics
A a ge popula ion o 400 den is s was selec ed om a
la ge popula ion o 2,047 den is s wo king in Wes e n
Andalusia. The den is s we e equally ec ui ed om he
h ee p o inces o Se ille (34%), Cadiz (33%) and Huel a
(33%). Fo he 400 den is s who p o ided opinion da a
396 p o ided demog aphic da a (Table 4). These we e
di ided be ween male and emale as 190 (47.5%) and 210
(52.5%), espec i ely. They had 10.59±8.39 and 9.26±7.52
yea s o expe ience, espec i ely (P =0.095). The mean
(±SD) yea s o expe ience o he o al esponden s was
9.20±7.97 ( ange 0 o 37) yea s. Two hund ed and six y-
one o esponden s (65%) wo ked only in p i a e clinics,
46 (12 %) in public sec o clinics and 89 (22%) in bo h
p i a e and public sec o clinics. The e was no di e ence
be ween bo h sexes (P =0.114). One hund ed and hi y-
wo esponden s (33%) wo ked in u ban se ings, 177 (44%)
in subu ban se ings, and 87 (22%) in bo h. The e was a sig-
ni ican sex di e ence in he dis ibu ion (P =0.001). While
27 (31%) o 190 males wo ked in bo h u ban and subu ban
clinics, he co esponding igu e o emales was 60 o 206
(69%) (Table 4).
KOVP. Knowledge, alue, opinion and p ac ice a ound
pi and issu e sealan s we e examined, i s as g oups and
hen by demog aphics. As a g oup he a e age alues
we e: knowledge = 3.57 ± 0.47; opinion = 2.48 ± 0.47;
p ac ice = 3.48 ± 0.50; and alue = 2.74 ± 0.52. The g oups
we e hen seg ega ed by ou me ics: sex, yea s o expe i-
ence, p ac ice sec o and place o wo k (16 o al
assessmen s) (Table 5). The sco es wi hin he 16 me ics
anged om 2.37 o 3.67 (1=s ongly disag ee; 5=s ongly
ag ee), indica ing a neu al o posi i e imp ession o pi
and issu e sealan s.
As indica ed in Table 5, o he 16 assessmen s, 5
demons a ed s a is ically signi ican di e ences: Knowledge
di e ed by yea s o expe ience (p=0.00), and place o wo k
(p = 0.00); Opinion di e ed by yea s o expe ience (p=0.03)
and sec o (p=0.00). Simila ly, p ac ice abou sealan s
di e ed by yea s o expe ience (p=0.00). Con e sely, alues
a ound sealan placemen did no s a is ically di e by sex,
yea s o expe ience, p ac ice sec o o place o wo k.
The co ela ions be ween knowledge, opinion, alues
and p ac ice is p esen ed in Table 6. S a is ically signi i-
can co ela ions we e ound be ween knowledge and
p ac ice ( =0.44, p=0.00) and be ween alue and opinion
( =0.35, p=0.00).
Discussion
These p ima y indings indica e ha den is s in wes e n
Andalusia ha e neu al o a o able knowledge, opinion,
alues, and p ac ice a i udes abou sealan s (Table 3). The
mo e de ailed s a is ical indings o KOVP in ela ionship
o demog aphics (Tables 5 and 6) need o be in e p e ed
wi h cau ion. Fi s , some a e, and some a e no signi ican .
Ye , o hose ha a e signi ican , he absolu e di e ences
be ween he highes and lowes alues in each ca ego y o
KOVP a e modes . Second, hese a e seconda y ou comes
o associa ion, and should be iewed as hypo hesis
Table 2 To iden i y he cu en bes e idence on knowledge, a i udes and p ac ice ega ding pi and issu e sealan s
we que ied MEDLINE using he ollowing sea ch s a egy
S ep Sea ch Found
1 (den al sealan s) OR ( oo h sealan s) OR ( issu e sealan s) OR (pi and issu e sealan s) 3058
2 (Heal h ca e quali y, access, e alua ion) OR (pa ien ca e managemen ) OR (beha io and beha io mechanisms) 2,228,959
3 1 AND 2 318
4 2008[PDa ]:2012[PDa ] 3,756,585
5 3 AND 4 78
Rele an = 7
Sea ch #2 was limi ed o su eys o on KAP ega ding sealan s. The i les and abs ac s we e examined o iden i y clinical ials ele an o pi and issu e sealan s.
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Table 3 Dis ibu ion and mean ± s anda d de ia ion o sco es o he ques ions
QUESTIONS Pe cen ages *Mean ± SD
12345
S ongly
disag ee
Disag ee Neu al Ag ee S ongly
ag ee
Knowledge
Q1 I hink ha he e ec i eness o issu e
sealan s is suppo ed by s ong scien i ic
e idence.
5.5 8.5 21.8 27.2 37.0 3.82±1.18
Q2 The e is scien i ic e idence o he
es o a i e use o den al sealan s.
7.0 15.5 35.5 22.2 19.8 3.32±1.16
Q3 I am amilia wi h he echnique o placing
den al sealan s.
6.8 3.8 14.8 33.5 41.2 3.99±1.15
Q4 I belie e ha issu e sealan s should be
e iewed a e placemen .
1.8 2.0 14.0 30.0 52.2 4.29±0.90
Q5 I unde s and he ins uc ions o placing
sealan s.
1.8 3.0 26.0 27.2 42.0 4.05±0.98
Q6 I hink ha sealan s should only be used on
newly e up ed ee h
21.8 14.2 21.5 20.0 22.5 3.07±1.45
Q7 I hink ha sealan s wea ou easily. 6.0 17.5 32.8 26.2 17.5 3.32±1.13
Q8 I belie e ha you mus pe o m a ca ies isk
assessmen o p e en o e ea men .
4.8 3.0 26.2 34.2 31.8 3.85±1.05
Q9 Pi and issu e sealan s ha e ad e se e ec s. 28.5 21.5 25.0 14.8 10.2 2.57±1.31
Q10 I belie e he echnique o applying a sealan
is he mos impo an aspec o he success
o he ea men .
9.5 10.8 28.0 28.8 23.0 3.45±1.22
Q11 I ag ee ha esin sealan s a e mo e e ec i e
han glass ionome sealan .
7.6 13.0 33.6 27.0 18.8 3.36±1.15
Q12 The mos impo an ac o o adhesion o
occu in sealan placemen is p ope acid
e ching.
6.8 5.5 26.2 34.8 26.7 3.69±1.13
Value
Q13 I hink his echnique akes ime o do
co ec ly.
39.0 35.2 19.5 5.8 0.5 1.94±0.92
Q14 The ma e ials ha a e used o he
placemen o sealan s a e e y expensi e.
23.1 38.7 25.1 10.8 2.3 2.30±1.01
Q15 I do no use sealan s e y o en as a
p e en i e me hod because i s e ec is
sho li ed.
25.0 28.2 18.0 19.5 9.2 2.60±1.30
Q16 Fissu e sealan s a e used less han hey
should be.
9.5 6.8 27.1 31.4 25.1 3.56±1.21
Q17 The den al s a a my clinic communica e
impo ance o using sealan s o he pa ien s.
8.9 13.5 36.1 19.6 21.9 3.32±1.21
Opinion
Q18 I is di icul o explain o pa ien s wha
den al sealan s a e.
25.5 21.2 21.8 25.8 5.8 2.65±1.27
Q19 I is di icul o jus i y he cos o sealan s o
pa en s
15.8 18.3 31.3 22.6 12.0 2.97±1.24
Q20 I hink my pa ien s unde s and he bene i s
o using sealan s.
28.0 23.0 31.1 9.3 8.6 2.47±1.23
Q21 I is necessa y o p omo e he use o
sealan s amongs den is s and den al
educa o s.
4.0 11.8 19.3 30.6 34.3 3.79±1.15
Q22 I apply sealan s because he o al public
heal h communi y ins uc s me o.
55.9 23.5 13.6 4.7 2.3 1.74±1.02
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gene a ing. The s udy was powe ed o he p ima y ou -
come a iables, no he seconda y ou come a iables.
The e o e, he analyses in Tables 5 and 6 a e ulne able o
ype 1 o ype 2 e o s. In sum, he indings epo ed he e:
(1) adds Spain o a lis o o he coun ies in wha appea s
o be a g owing global phenomenon o unde -u iliza ion
o he p e en i e sealan s [14-19,27]; and (2) expands he
lis o beha io al me ics a ound den al sealan knowledge
and a i udes o include opinions and alues ha do no
appea o adequa ely ela e p ac ice beha io . The su ey
did no , howe e : (1) de e mine he ela ionship o KOVP
o ac ual sealan use; o (2) de e mine he ela ionship o
adi ional KAP wi h KOVP.
A oubling o e all inding is he ecogni ion o a clinical
p oblem (ca ies), he a ailabili y o a cos -e ec i e p e en -
i e solu ion (sealan s), a neu al o posi i e KOVP, and he
eluc ance o he p o essional communi y o implemen
sealan s in p ac ice. This sugges s ha beha io al phenom-
ena o he han o in addi ion o KOVP may be d i ing clin-
ical p ac ice.
One hypo hesis is ha he heo e ical KOVP impa ed
du ing den al school aining di e s om clinical aining.
Table 4 Demog aphics
Sex
Male Female
N Mean ± SD n (%) Mean ± SD n (%) P
396 190 48.0 206 52.0
Yea s o expe ience 10.59±8.39 9.26±7.52 0.095
Sec o Public 46 28 (60,9) 18 (39,1) 0.114
P i a e 261 117 (44,8) 144 (55,2)
Bo h 89 45 (50,6) 44 (49,4)
Place o wo k U ban 132 74 (56,1) 58 (43,9) 0.001
Subu b 177 89 (50,3) 88 (49,7)
Bo h 87 27 (31,0) 60 (69,0)
Table 3 Dis ibu ion and mean ± s anda d de ia ion o sco es o he ques ions (Con inued)
Q23 I use den al sealan in he o al public sec o
because i is easy o apply and pa ien s ind
i com o able.
66.5 15.8 16.3 1.5 0.0 1.53±0.82
Q24 Since wo king in he o al heal h public
communi y, I ha e g ea e belie in he
e ec i eness o sealan s.
42.9 18.4 25.9 8.0 4.7 2.13±1.19
P ac ice
Q25 I some imes a oid den al sealan s o he
possibili y o sealing o e ca ies.
14.2 15.0 23.0 22.8 25.0 3.29±1.37
Q26 I hink sealan s, besides being a p e en i e
me hod, can also ha e a es o a i e e ec
and can be used on incipien ca ies.
35.6 25.1 17.8 13.3 8.3 2.34±1.30
Q27 This sealing echnique, when used
alongside luo ide applica ion, may educe
he a e o decay mo e signi ican ly.
5.5 8.0 30.5 24.5 31.5 3.68±1.16
Q28 In he case o pa ial o o al loss o sealan ,
I would ecommend eapplica ion.
6.8 13.1 21.2 25.9 33.0 3.65±1.25
Q29 The mos impo an ac o o adhesion o
occu in sealan placemen is p ope
insola ion.
2.5 5.0 17.6 37.8 37.0 4.02±0.99
Q30 The mos impo an ac o o adhesion o
occu in sealan placemen is p ope acid
e ching.
4.0 5.3 27.9 38.9 23.9 3.73±1.01
Q31 The bene i s o using sealan s should be
conside ed wi h ega d o he pa ien ’s isk
o ca ies and clinicians should ollow speci ic
guidelines
2.8 8.1 38.5 25.9 24.7 3.62±1.03
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Fo example, o e he las 100 yea s den is s ha e success-
ully ea ed ca ies wi h su ge y and epai using sil e
amalgam, plas ic, gold o s ainless s eel. Den al schools
he e o e ocus on p o iding aining o ins ill basic
knowledge o ana omy, anes hesia, ma e ial science, and
clinical skill o acili a e su gical expe ise in epai ing
he ca i a ed lesion. In pa allel, compensa ion sys ems
ha e e ol ed o ewa d clinicians o p o iding su gical
ca e. This sys em he e o e ewa ds ea men o e
p e en ion.
Howe e , o mo e han 50 yea s, he o al heal h commu-
ni y has ecognized ha ca ies is a p e en able in ec ion,
and de eloped me hods o educe he p obabili y o ini i-
a ion and p og ession o he in ec ion. The mos e ec i e
p e en i e me hod o occlusal ca ies is he applica ion o
pi and issu e sealan s o he occlusal su aces [3-13],
which can educe den al decay by up o 80%. Ye , globally,
he epidemic o ca ies con inues unaba ed [1,2].
F om a global o al heal h pe spec i e, e ec ing sys ema ic
change in clinical ca e deli e y o suppo p e en ion is
challenging [14-19,27]. This is also ue his o ically ac oss
he heal h spec um, anging om he use o i amin C o
Table 6 Rela ionship be ween mean knowledge, alues,
opinions and p ac ice
Knowledge Value Opinion P ac ice
Spea man’s co ela ion
Knowledge 1.000 0.054 0.056 0.439
**
. P=0.287 P=0.441 P=0.000
(N= 385) (N= 385) (N=192) (N=384)
Value 0.054 1.000 0.351
**
0.002
P=0.287 . P=0.000 P=0.966
N=385 (N=390) N=191 N=383
Opinion 0.056 0.351
**
1.000 −0.003
P=0.441 P=0.000 . P=0.965
N=192 N=191 N=194 N=189
P ac ice 0.439
**
0.002 −0.003 1.000
P=0.000 P=0.966 P=0.965 .
N=384 N=383 N=189 N=390
** Co ela ion is signi ican a he 0.01 le el (2- ailed).
Table 5 Summa y able o knowledge, alues, opinion, p ac ice
Knowledge (Q 1–12) Value (Q 13–17) Opinion (Q 18–24) P ac ice (Q 25–31) To al (Q 1–31)
Mean±SD
1 Sex
Male (n=187) 3.55±0.42 2.76±0.51 2.50±0.42 3.47±0.50 3.14±0.30
Female (n=204) 3.58±0.52 2.73±0.53 2.45±0.51 3.48±0.50 3.15±0.31
To al (n=391) 3.57±0.47 2.74±0.52 2.48±0.47 3.48±0.50 3.15±0.31
P=0.44 P=0.55 P=0.41 P=0.82 P=0.76
2 Yea s o Expe ience
≤3 (n=38) 3.64±0.33 2.79±0.52 2.61±0.53 3.47±0.47 3.17±0.28
4-15 (n=89) 3.60±0.43 2.73±0.51 2.49±0.41 3.57±0.46 3.19±0.28
≥16 (n=57) 3.42±0.63 2.72±0.55 2.37±0.49 3.30±0.56 3.06±0.35
To al (n=184) 3.57±0.47 2.74±0.52 2.48±0.47 3.48±0.50 3.15±0.31
P=0.00* P=0.71 P=0.03* P=0.00* P=0.03*
3 Sec o
Public 3.67±0.33 2.78±0.35 2.39±0.38 3.48±0.44 3.18±0.25
P i a e 3.56±0.50 2.72±0.54 2.35±0.51 3.49±0.51 3.06±0.38
Bo h 3.52±0.46 2.81±0.53 2.65±0.42 3.43±0.51 3.21±0.24
To al 3.57±0.47 2.74±0.52 2.48±0.47 3.48±0.50 3.15±0.31
P=0.23 P=0.39 P=0.00* P=0.62 P=0.01*
4 Place o Wo k
U ban 3.43±0.56 2.73±0.50 2.46±0.53 3.40±0.54 3.05±0.34
Sub-u ban 3.65±0.42 2.79±0.55 2.47±0.42 3.50±0.47 3.22±0.28
Bo h 3.58± 0.36 2.69±0.49 2.52±0.45 3.52±0.49 3.18±0.25
To al 3.57±0.47 2.74±0.52 2.48±0.47 3.48±0.50 3.15±0.31
P=0.00* P=0.33 P=0.77 P=0.13 P=0.00*
*Signi ican di e ence.
San Ma in e al. BMC O al Heal h 2013, 13:12 Page 6 o 8
h p://www.biomedcen al.com/1472-6831/13/12
p e en scu y (250 yea s be o e ou ine implemen a ion)
[28], o hand washing (100 yea s be o e ou ine implemen-
a ion) [29], o a hos o in e en ions and diagnos ics ha
o e ea , unde ea o mis ea pa ien s (mo e han 15
yea s o ou ine implemen a ion) [30].
F om a beha io al iewpoin , mul iple models ha e been
sugges ed o e ec beha io change. [31,32]. Pionee ing
wo k by Bone i and colleagues [20,27,33] examined six
heo e ical models o beha io change a ound sealan
use. They include: ac ion planning, common sense sel -
egula ion model, ope an lea ning heo y, he p ecau ion
adop ion p ocess, social cogni i e heo y, and he heo y
o planned beha io . Thei examina ion included know-
ledge as an addi ional p edic o . Using mul iple eg ession
analysis, hey ound ha hese models o beha io
accoun ed o only 38% in he a ia ion in ca e. This again
sugges s ha he cu en models o e ec ing clinical
p ac ice beha io change do no go a enough in iden i y-
ing signi ican le e s o change. Thei wo k does sugges ,
howe e , ha economic and legal mechanisms may be
mo e e ec i e in al e ing clinical p ac ice.
In Spain, he Na ional Heal h Sys em p o ides ca e o
all child en, independen o pa en al income. S a e o e-
gional p og ams can supplemen his ca e. In Andalusia,
wo amewo ks o o al ca e a e a ailable: public and p i-
a e. P i a e den is s ecei e 36 eu os o p o iding ca e.
In con as , den is s wo king in he public sec o a e on
sala y and emune a ion is independen o he ype o ca e
hey p o ide. This compensa ion sys em o he p i a e
sec o may be a signi ican ac o impac ing he selec ion
o ca e deli e ed. Simila ly, he cos o ma e ials ( luo ide
a nish, glass ionome , composi e, and amalgam) can im-
pac he selec ion o ca e in he public sec o since unds
o pu chasing a e limi ed. Thus, economics, no KOVP,
may be he p ac ice d i e s in Spain. In e es ingly, Cla kson
e al. examined he economic/educa ion/ alues hypo hesis.
They ound ha only economics al e ed p ac ice beha io
by den is s [20]. The cu en indings ha KOVPa e
no p edic i e o p ac ice, combined wi h he indings o
Cla kson e al., sugges ha al e na e app oaches o p ac ice
change and imp o ing child en’s o al heal h a e needed.
Wo k a he Ha a d Business School sugges s ha
ocusing on alues may be he key d i e o heal h im-
p o emen [34-36]. This g oup pos ula es and p o ides
examples o sys ems ha ocus on ewa ding alue (de ined
as ou comes/cos s o he ca e cycle). These sys ems in-
c ease access o ca e, imp o e heal h, and educe he cos s
o ca e. The sys ems he Ha a d eam examined who use
a alues app oach ha e: inc eased access o ca e, imp o ed
heal h, and educed he cos s o ca e. The Commonweal h
Fund, in an ex ensi ely documen ed epo , suppo s a
alue-based app oach o ca e imp o emen [37]. Fu he
suppo o his concep , as i applies o o al heal h im-
p o emen in he U.S. comes om he Pew T us epo
[38]. The Pew T us ound ha sealan s a e unde used,
esul ing om wo signi ican ba ie s o ca e: legal and
economic.
In sum, he imp o emen o o al heal h, h ough he
inc eased use o sealan s, does no appea o be ela ed o
imp o ing knowledge, a i udes, opinion o alues o he
den al communi y. Ra he , economic and legal a iables
appea o p o ide mo e le e age. The o al heal h commu-
ni y mus now conside i , when, and how we migh begin
o es hese new hypo hesis.
Conclusions
The esul s epo ed he e sugges ha , simila o o he coun-
ies, Andalusian den is s know ha sealan s a e e ec i e,
ha e neu al o posi i e a i udes owa d sealan s; hough,
based on epidemiological s udies, unde use sealan s. The e-
o e, me hods o he han classical beha io change (eg: inan-
cial o legal mechanisms) will be equi ed o change p ac ice
pa e ns aimed a imp o ing child en's o al heal h.
Compe ing in e es s
The au ho s decla e no compe ing in e es .
Au ho s’con ibu ions
LSM, AC and MB concep ualized and designed he s udy, LSM collec ed he
da a, LSM, MT, RN and EOO analyzed he da a and d a ed he manusc ip .
All au ho s ead and app o ed he inal manusc ip .
Acknowledgemen s
The au ho s would like o hank he Vice ec o ado de In es igacion o he
Uni e si y o Se ille, Ha a d School o Den al Medicine, and he Fo sy h
Ins i u e. We would also like o hank he ollowing clinicians who
pa icipa ed in he alida ion o he su ey: D s. Anibal Gonzalez, Ra ael
Llamas, Ma ia del Aguila Co de o, Da id Ribas, Emilio Lledo, Manuel Poya o,
An onio Fe nandez. We acknowledge he ollowing sou ces o in aluable
inancial suppo NIMHD 1 R34 DE022272 (NIH2385) and NIDCR 1 U24
MD006964. We a e g a e ul o D . Ja ie Gil o assis ance wi h he s a is ical
analysis.
Au ho de ails
1
School o Den is y, Uni e si y o Se ille, A icena s/n, Se ille, Spain.
2
Fo sy h
Ins i u e, Camb idge, MA, USA.
3
Ha a d School o Den al Medicine Bos on,
Bos on, MA, USA.
4
School o Den is y, Uni e si y o Se ille, Se ille, Spain.
5
School o Den is y, Uni e si y o G anada, G anada, Spain.
6
Fo sy h Ins i u e,
Camb idge, MA, USA.
7
Ha a d School o Den al Medicine, Bos on, MA, USA.
8
Fo sy h Ins i u e, Camb idge, MA, USA.
9
Facul y o Den is y, Oba emi
Awolowo Uni e si y, Ile-I e, Nige ia.
Recei ed: 29 Augus 2012 Accep ed: 28 Janua y 2013
Published: 8 Feb ua y 2013
Re e ences
1. Benzian H, Hobdell M, Holmg en C, Yee R, Monse B, Ba na d JT, an
Palens ein HW: Poli ical p io i y o global o al heal h: an analysis o
easons o in e na ional neglec . In Den J 2011, 61(3):124–30.
2. Pi s N, Amaechi B, Niede man R, Ace edo AM, Vianna R, Ganss C, Ismail A,
Honkala E: Global o al heal h inequali ies: den al ca ies ask g oup—
esea ch, agenda. Ad Den Res 2011, 23(2):211–20.
3. Mickenau sch S, Yengopal V: Ca ies-p e en i e e ec o glass ionome
and esin-based issu e sealan s on pe manen ee h: An upda e o
sys ema ic e iew e idence. BMC Res No es 2011, 4(1):22. PubMed PMID:
21276215; PubMedCen al PMCID: PMC3041989.
4. Hii i A, Aho uo-Salo an a A, No dblad A, Mäkelä M: Pi and issu e sealan s
e sus luo ide a nishes o p e en ing den al decay in child en and
San Ma in e al. BMC O al Heal h 2013, 13:12 Page 7 o 8
h p://www.biomedcen al.com/1472-6831/13/12
adolescen s. Coch ane Da abase Sys Re 2010, 17(3):CD003067. Re iew.
PubMed PMID: 20238319.
5. Yengopal V, Mickenau sch S: Resin-modi ied glass-ionome cemen s
e sus esin-based ma e ials as issu e sealan s: a me a-analysis o
clinical ials. Eu A ch Paedia Den 2010, 11(1):18–25. Re iew. PubMed
PMID: 20129029.
6. Gooch BF, G i in SO, G ay SK, Kohn WG, Rozie RG, Siegal M, Cen e s o
Disease Con ol and P e en ion, e al:P e en ing den al ca ies h ough
school-based sealan p og ams: upda ed ecommenda ions and e iews
o e idence. J Am Den Assoc 2009, 140(11):1356–65. Re iew. PubMed
PMID: 19884392.
7. Yengopal V, Mickenau sch S, Beze a AC, Leal SC: Ca ies-p e en i e e ec
o glass ionome and esin-based issu e sealan s on pe manen ee h: a
me a analysis. J O al Sci 2009, 51(3):373–82. Re iew. PubMed PMID:
19776504.
8. Ma inho VC: Ma inhozed ials o luo ide he apies o p e en ing den al
ca ies. Eu A ch Paedia Den 2009, 10(3):183–91. Re iew. PubMed PMID:
19772849.
9. G i in SO, G ay SK, Mal i z DM, Gooch BF: Ca ies isk in o me ly sealed
ee h. J Am Den Assoc 2009, 140(4):415–23. Re iew. PubMed PMID:
19339530.
10. Aho uo-Salo an a A, Hii i A, No dblad A, Mäkelä M, Wo hing on HV: Pi and
issu e sealan s o p e en ing den al decay in he pe manen ee h o
child en and adolescen s. Coch ane Da abase Sys Re 2008, 8(4):CD001830.
Re iew. PubMed PMID: 18843625.
11. Aza pazhooh A, Main PA: Pi and issu e sealan s in he p e en ion o
den al ca ies in child en and adolescen s: a sys ema ic e iew. J Can
Den Assoc 2008, 74(2):171–7. Re iew. PubMed PMID: 18353204.
12. Beauchamp J, Cau ield PW, C all JJ, Donly K, Feigal R, Gooch B, Ame ican
Den al Associa ion Council on Scien i ic A ai s, e al:E idence-based
clinical ecommenda ions o he use o pi -and- issu e sealan s: a epo
o he Ame ican Den al Associa ion Council on Scien i ic A ai s. JAm
Den Assoc 2008, 139(3):257–68. Re iew. PubMed PMID: 18310730.
13. G i in SO, Oong E, Kohn W, Vidako ic B, Gooch BF, Bade J, Cla kson J,
Fon ana MR, Meye DM, Rozie RG, Wein aub JA, Ze o DT, CDC Den al
Sealan Sys ema ic Re iew Wo k G oup: The e ec i eness o sealan s in
managing ca ies lesions. J Den Res 2008, 87(2):169–74. PubMed PMID:
18218845.
14. Tellez M, G ay SL, G ay S, Lim S, Ismail AI: Sealan s and den al ca ies:
den is s' pe spec i es on e idence-based ecommenda ions. J Am Den
Assoc 2011, 142(9):1033–40.
15. Riley JL, Richman JS, Rindal DB, Fellows JL, Q is V, Gilbe GH, Go dan VV,
Den al PBRN Collabo a i e G oup: Use o ca ies-p e en i e agen s in
child en: indings om he den al p ac ice-based esea ch ne wo k. O al
Heal h P e Den 2010, 8(4):351–9. PubMed PMID: 21180672; PubMed
Cen al PMCID: PMC3074637.
16. Fe acane J, Hil on T, Ko pak A, Gille e J, McIn y e PS, Be g J, PRECEDENT
No hwes : Use o ca ies p e en ion se ices in he No hwes
PRECEDENT den al ne wo k. Communi y Den O al Epidemiol 2011, 39(1):
69–78. doi:10.1111/j.1600-0528.2010.00570.x. Epub 2010 No 29. PubMed
PMID: 21114514; PubMed Cen al PMCID: PMC3031425.
17. Michalaki M, Si akaki M, Oulis CJ, Lygidakis NA: A i udes, knowledge and
u iliza ion o issu e sealan s among G eek den is s: a na ional su ey.
Eu A ch Paedia Den 2010, 11(6):287–93.
18. Oulis CJ, Be douses ED, Mamai-Homa a E, Polych onopoulou A: P e alence
o sealan s in ela ion o den al ca ies on he pe manen mola s o 12
and 15-yea -old G eek adolescen s. A na ional pa h inde su ey”.
BMC Public Heal h 2011, 11:100.
19. Sa madi R, Gahnbe g L, Gab e P: Clinicians' p e en i e s a egies o
child en and adolescen s iden i ied as a high isk o de eloping ca ies.
In J Paedia Den 2011, 21(3):167–74. doi:10.1111/j.1365-263X.2010.01103.x.
Epub 2010 Oc 21.
20. Cla kson JE, Tu ne S, G imshaw JM, Ramsay CR, Johns on M, Sco A,
Bone i D, Tilley CJ, Maclennan G, Ibbe son R, Macphe son LM, Pi s NB:
Changing clinicians' beha io : a andomized con olled ial o ees and
educa ion. J Den Res 2008, 87(7):640–4.
21. Alme ich Silla JM, Mon iel Company JM: O al heal h su ey o he child
popula ion in he Valencia Region o Spain (2004). Med O al Pa ol O al Ci
Bucal 2006, 11(4):E369–81. 1.
22. Llod a Cal o JC: Encues a de salud o al en España 2010. RCOE 2012,
17(1):13–46.
23. B a o M, Baca P, Llod a JC, Oso io E: A 24-mon h s udy compa ing sealan
and luo ide a nish in ca ies educ ion on di e en pe manen i s
mola su aces. J Public Heal h Den 1997, 57(3):184–6.
24. B a o M, Mon e o J, B a o JJ, Baca P, Llod a JC: Sealan and luo ide
a nish in ca ies: a andomized ial. J Den Res 2005, 84(12):1138–43.
25. Ma ino S: O al heal h beha io al and social in e en ion esea ch
concep s and me hods. J Public Heal h Den 2011, 71(Suppl 1):S2–6.
26. G eenhalgh T, Robe G, Mac a lane F, Ba e P, Ky iakidou O: Di usion o
inno a ions in se ice o ganiza ions: sys ema ic e iew and
ecommenda ions. Milbank Q 2004, 82(4):581–629.
27. Bone i D, Johns on M, Cla kson J, Tu ne S: Applying mul iple models o
p edic clinicians' beha iou al in en ion and objec i e beha iou when
managing child en's ee h. Psychol Heal h 2009, 24(7):843–60.
28. Magio kinis E, Beloukas A, Diaman is A: Scu y: pas , p esen and u u e.
Eu J In e n Med 2011, 22(2):147–52. Epub 2010 No 16.
29. Chou DT, Achan P, Ramachand an M: The Wo ld Heal h O ganiza ion '5
momen s o hand hygiene': he scien i ic ounda ion. J Bone Join Su g B
2012, 94(4):441–5. Re iew.
30. G een BL, Li L, Mo is JF, Gluzman R, Da is JL, Wang MQ, Ka z RV: De ailed
knowledge o he Tuskegee syphilis s udy: who knows wha ? A
amewo k o heal h p omo ion s a egies. Heal h Educ Beha 2011, 38(6):
629–36. Epub 2011 Ap 11.
31. San Ma in L: Análisis sob e el uso de sellado es de hoyos, su cos y isu as
po los p o esionales Andaluces. [ esis doc o al]. Se illa: Se illa Uni e si y;
2012.
32. Niede man R, Richa ds D, B ands W: The changing s anda d o ca e. JAm
Den Assoc 2012, 143(5):434–7.
33. Bone i D, Johns on M, Pi s NB, Dee y C, Ricke s I, Tilley C, Cla kson JE:
Knowledge may no be he bes a ge o s a egies o in luence
e idence-based p ac ice: using psychological models o unde s and RCT
e ec s. In J Beha Med 2009, 16(3):287–93.
34. Po e ME, Teisbe g EO: Rede ining heal h ca e: c ea ing alue-based
compe i ion on esul s. Camb idge MA: Ha a d Business School P ess; 2006.
35. Po e ME: Wha is alue in heal h ca e? N Engl J Med 2010,
363(26):2477–81.
36. Kaplan RS, Po e ME: How o sol e he cos c isis in heal h ca e. Ha Bus
Re 2011, 89(9):46–52. 54, 56–61.
37. Schoen C, Gu e man S, Zezza M, Ab ams M: Con on ing Cos s. S abilizing U.
S. heal h spending while mo ing owa d a high pe o mance heal h ca e
sys em. NY: The Commonweal h Fund Commission on a High Pe o mance
Heal h Sys em; 2013.
38. Pew Cen e on he S a es: Falling Sho . Mos s a es lag on den al sealan s.
Washing on DC: The Pew Cha i able T us s; 2013.
doi:10.1186/1472-6831-13-12
Ci e his a icle as: San Ma in e al.:Den al sealan knowledge, opinion,
alues and p ac ice o Spanish den is s. BMC O al Heal h 2013 13:12.
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