Knowledge, attitudes, and referral behavior of pediatric dentists regarding the early diagnosis of orthodontic anomalies: a cross-sectional survey

Technical Summary: Knowledge, Attitudes, and Referral Behavior of Pediatric Dentists Regarding Early Diagnosis of Orthodontic Anomalies

Problem Statement
Pediatric dentists serve as the primary gatekeepers for orthodontic care, often being the first clinicians to detect developing malocclusions during the primary and early mixed dentition. While early detection allows for interceptive measures that can guide growth and reduce the severity of future problems, the specific knowledge, attitudes, and referral behaviors of pediatric dentists regarding the early diagnosis of these anomalies have not been well characterized. Previous literature has highlighted variability in referral patterns and confidence levels across different settings, yet few studies have simultaneously evaluated the knowledge base, professional attitudes, and actual referral behaviors of pediatric dentists specifically concerning the timing and identification of developmental anomalies. Furthermore, the adequacy of undergraduate education in preparing clinicians for these diagnostic responsibilities has been questioned.

Methodology
This study employed a cross-sectional, questionnaire-based design conducted between January and February 2026. The research adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) and received ethical approval from the Non-Interventional Researches Ethics Committee of Kocaeli Health and Technology University.

• Participants: A convenience sample of 120 pediatric dentists was recruited via social media (Instagram), professional messaging groups (WhatsApp), and a national pediatric dentistry association. The sample was predominantly female (83.3%) and early-career, with 68.3% having 0–5 years of postgraduate experience.
• Instrument: A 28-item anonymous online questionnaire was developed de novo based on American Academy of Pediatric Dentistry (AAPD) guidelines and validated by an expert panel. The instrument comprised four sections:
  1. Demographic and professional characteristics.
  2. Knowledge of early diagnosis (11 items, scored 0–11).
  3. Attitudes and awareness (7 items on a 5-point Likert scale).
  4. Clinical practice and referral behavior.
• Analysis: Data were analyzed using Python. Knowledge scores were categorized as poor (≤5), moderate (6–8), or good (9–11). Statistical comparisons utilized the Mann-Whitney U and Kruskal-Wallis tests for continuous variables and chi-square or Monte Carlo tests for categorical associations. Significance was set at p < 0.05, with Benjamini-Hochberg correction for multiple comparisons. Internal consistency was assessed via Kuder-Richardson 20 (KR-20) for knowledge and Cronbach's alpha for attitudes.

Key Results

• Knowledge Levels: The mean knowledge score was 8.28 ± 1.41 out of 11. Participants were distributed as follows: 44.2% good, 50.0% moderate, and 5.8% poor. While performance was high on general concepts (e.g., consequences of untreated crossbite), significant gaps existed in specific timing and diagnostic criteria. The lowest correct-response rates were observed for:
  • Optimal timing of unilateral posterior crossbite treatment (20.8%).
  • Management of an open-bite clinical vignette (46.7%).
  • Recommended age for the first orthodontic evaluation (61.7%).
  • Spontaneous closure age of physiologic diastema (69.2%).
• Attitudes: Attitudes were overwhelmingly positive. Over 94% of respondents agreed on the importance of diagnostic knowledge, the value of early referral, and the necessity of communication with orthodontists. However, only 37.5% agreed that their undergraduate education provided adequate time for orthodontic anomalies.
• Practice and Referral: The median number of referrals in the preceding six months was 20. A significant association was found between the frequency of collaboration with orthodontists and the number of referrals (p = 0.006), with routine collaborators referring more patients. Conversely, 26.7% of respondents reported not following up with patients after referral.
• Associations: The knowledge score showed no significant association with demographic variables (gender, age, experience, workplace). However, knowledge scores were weakly but significantly correlated with attitude scores (ρ = 0.254, p = 0.005). Notably, knowledge scores did not correlate with the frequency of routine screening or the volume of referrals, indicating a disconnect between knowledge/attitude and preventive practice.

Significance and Claims
The authors claim that pediatric dentists possess moderate knowledge with a strong positive attitude toward early diagnosis, yet a distinct gap exists between these favorable attitudes and self-reported preventive practices. The study identifies that knowledge deficits are not isolated to specific subgroups but appear systemic, particularly regarding the timing of interceptive treatment and the recommended age for initial evaluation.

The paper posits that the perception of inadequate undergraduate preparation (reported by the majority) and the lack of correlation between knowledge and referral volume suggest a need for targeted interventions. Specifically, the authors argue that strengthening education and continuing professional development should focus on the specific timing of early intervention rather than general knowledge. Furthermore, fostering structured collaboration and feedback pathways between pediatric dentists and orthodontists is warranted to improve referral continuity and ensure timely care.

Limitations
The authors acknowledge several limitations, including the use of a convenience sample which limits generalizability, the potential for social desirability bias in self-reported data, and the cross-sectional design which precludes causal inference. Additionally, the low internal consistency of the knowledge scale (KR-20 = 0.281) suggests that knowledge items should be interpreted individually rather than as a unidimensional scale. The study was conducted in a single country, and the sample was predominantly female and early-career.