Dental sealant knowledge, opinion, values and practice of Spanih dentists

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. San Ma in e al. BMC O al Heal h 2013, 13:12 Page 2 o 8 h p://www.biomedcen al.com/1472-6831/13/12 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. San Ma in e al. BMC O al Heal h 2013, 13:12 Page 3 o 8 h p://www.biomedcen al.com/1472-6831/13/12 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 San Ma in e al. BMC O al Heal h 2013, 13:12 Page 4 o 8 h p://www.biomedcen al.com/1472-6831/13/12 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 San Ma in e al. BMC O al Heal h 2013, 13:12 Page 5 o 8 h p://www.biomedcen al.com/1472-6831/13/12 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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