In a more recent study, DiGioacchino and colleagues¹⁸ surveyed dentists and dental hygienists about their current prevention behaviors with regard to eating disorders. Fewer than 28 percent of dentists reported assessing their patients for oral signs of eating disorders and providing those who did with home dental care instructions; fewer than 17 percent of dentists reported arranging more frequent recall appointments for patients exhibiting oral signs of eating disorders; only 11 percent reported referring patients with oral signs of eating disorders; and only 6 percent participated in case management (that is, being an active member of the patient’s health care team) of patients with eating disorders.

The purpose of this study was to assess sex differences pertaining to current behaviors and beliefs among dentists with regard to the following: identification of oral manifestations of eating disorders, provision of oral treatment to those with oral manifestations, patient referral and case management of patients with behaviors indicative of an eating disorder. We asked the following research questions:

– Are there differences between male and female dentists regarding secondary prevention behaviors with respect to eating disorders?

– Are there differences in health beliefs between male and female dentists?

	SUBJECTS AND METHODS

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Study design. This study was part of a larger study that assessed roles, beliefs and current intervention efforts pertaining to eating disorders among dental professionals.^19–21 We determined sample size based on statistical significance, available resources (such as funding, time) and adequate representation of the population. To attain a confidence level of 95 percent and a margin of error of ± 5 percent, a minimum sample size of 385 would be needed for statistical significance.²² As part of this larger study, we used a cross-sectional study design and a randomized sample of general dentists who were members of the American Dental Association and the American Association of Women Dentists, as well as dental hygienists who were members of the American Dental Hygienists Association. In 2003/2004, we collected data via a self-administered questionnaire mailed to subjects. Potential subjects for the study consisted of 1,000 general dentists randomly selected from the 2003 American Dental Association membership list.²³ Of these 1,000 dentists, 111 were ineligible to participate owing to incorrect addresses or because they currently were not practicing as a dentist (as noted on their returned questionnaires or explained to us in telephone calls), leaving a total of 889 eligible dentists. Of the 889 eligible dentists who were selected to participate in the study, 207 returned completed questionnaires, yielding a response rate of 23 percent. (Six of these dentists did not state their sex, and we eliminated them from the study.)

Because of the underrepresentation of female dentists in the sample, we selected a second sampling of 628 female dentists who were members of the American Association of Women Dentists.²⁴ Of the 628 potential subjects, eight were ineligible owing to an incorrect address or because they were not practicing as a dentist. A total of 149 usable questionnaires were returned, yielding a response rate of 24.0 percent. The overall response rate for both samples was 23 percent. Response rates for both of these sampling frames are reasonable for this type of survey.²⁵

Variables. The questionnaire was an adapted version of an instrument used in a previous study assessing the secondary prevention of eating disorders among dental professionals.¹⁸ The questionnaire was based on constructs from the transtheoretical model²⁶ and the health belief model²⁷ to assess current behaviors, as well as current beliefs, perceptions and knowledge regarding eating disorders. We also included the demographic variables of sex, race, age, years in practice and location of employment.

Prevention practices. We included five items on the questionnaire to assess prevention practices. The five criterion-specific behaviors included the following:

– assessing dental patients for oral manifestations of an eating disorder;

– providing specific home dental care instructions to patients exhibiting oral manifestations of an eating disorder;

– arranging more frequent recall appointments for patients exhibiting oral manifestations of an eating disorder;

– referring patients who exhibit oral manifestations of an eating disorder;

– communicating with the patient’s primary care provider.^11,18

The authors administered a questionnaire that was based on constructs from the transtheoretical model and the health belief model.

For each behavior, we asked participants to describe their current activity according to the following stages, as described in the transtheoretical model framework²⁸:

– precontemplation: I am not currently (insert criterion-specific behavior) and I have no intention of doing so;

– contemplation: I am not currently (insert criterion-specific behavior) but have done so sometimes;

– action: I currently (insert criterion-specific behavior) and have been for the last six months;

– maintenance: I currently (insert criterion-specific behavior) and have done so for longer than six months.

A detailed description of this scale can be found elsewhere.²⁰

Health beliefs. We used seven measures to assess knowledge, beliefs and perceptions of eating disorders. These included perceived self-efficacy with regard to performing prevention behaviors; perceived severity of anorexia nervosa and bulimia nervosa and benefits of engaging in prevention efforts with respect to eating disorders; and knowledge with regard to oral cues of eating disorders and physical cues of anorexia nervosa and bulimia nervosa.

We adapted from a previous study¹⁸ measures of knowledge regarding orodental cues (nine items), physical cues of anorexia nervosa (nine items), physical cues of bulimia nervosa (nine items), perception of the severity of anorexia nervosa (20 items), perception of the severity of bulimia nervosa (20 items), perceived self-efficacy with regard to secondary prevention (six items) and perceived benefits of secondary prevention (seven items). Internal consistency of scales ranged from = .76 to .80.

Data collection. Each selected dentist received a letter explaining the study and a questionnaire, along with a self-addressed stamped envelope. To increase the response rate, we mailed a follow-up letter and another questionnaire to nonresponders two to three weeks after sending the initial survey. For those subjects who did not respond to the first or second mailing, we sent a postcard as a third reminder three weeks after the initial follow-up. University institutional review board approval was granted before we began the study.

Data analysis. We analyzed the data using statistical software (SPSS V.11, SPSS, Chicago). In addition to providing descriptive statistics, we compared response variables and stage of behavior regarding intention to perform a behavior between male and female dentists using the ² test of independence to test for significant differences. We used the Student t test to test for significant differences in mean age and mean number of years in practice. We used the Pearson product moment correlation coefficient to determine the correlation between dentists’ ages and number of years in practice.

Because age and number of years in practice were highly correlated (r = .93, P < .001), we eliminated the variable "age of dentists in years" from the analysis. We retained number of years in practice as an independent variable to examine the effects of experience in dental practice over time on response variables, stage of behavior and health belief constructs. We used logistic regression and analysis of covariance techniques to examine potential confounding effects between sex and number of years in practice. The level of statistical significance was set at .05.

	RESULTS

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Table 1 presents demographic characteristics of the survey respondents. The group was composed of 46 percent male dentists and 54 percent female dentists. The mean (± standard deviation [SD]) age of participants was 47.9 ± 10.6 years, with the majority of both male and female participants ranging in age between 40 and 59 years. Female participants were significantly (P < .001) younger (44.75 ± 9.62 years) than male participants (51.56 ± 10.42 years). The majority of respondents were white (89.7 percent). The mean [± SD] number of years in practice was 17.0 ± 9.1. Male dentists reported practicing for a significantly (P < .001) greater number of years (26.67 ± 10.30) than female dentists (16.98 ± 9.15). The preponderance of dentists reported practicing in the Midwest, South/Southeast and Southwest regions of the United States, followed by the Northeast (approximately 15 percent of dentists) and Northwest (12 percent).

Few dentists in this study reported arranging a more frequent recall schedule for patients with oral manifestations of eating disorders (26 percent in the action or maintenance stage), referring patients with oral manifestations of eating disorders to other health care providers (25 percent) and communicating with the patient’s primary care provider (19 percent). We observed statistically significant differences between male and female respondents with regard to referring patients with oral signs of eating disorders (² = 9.13, P = .028); more female dentists reported being in the maintenance stage of behavioral adoption compared with male dentists. However, we did not note any statistically significant differences between male and female dentists with regard to arranging more frequent recall appointments (² = 7.40, P = .060) or communicating with the patient’s primary care provider (² = 2.85, P = .416).

As described above, male and female dentists reported a significant difference in the number of years in practice, with female dentists reporting 9.69 fewer years in practice than male dentists. To control for the possibility that increased awareness of eating disorders might be associated with more recent training (that is, by dentists who had entered practice more recently), we ran logistic regression models using sex and years in practice as independent variables to predict each of the secondary prevention practices (specifically, the likelihood that practitioners were in the action or maintenance stages).

Owing to the small number of participants identified in the action and maintenance stages of behavior, we combined (aggregated) these two categories to create a single stage of behavior labeled "action." Similarly, we combined the pre-contemplation and contemplation stages to create a single stage of behavior labeled "no action." Previous research using the transtheoretical model also has combined stages into action and no action.^29–31

Logistic regression analyses. Table 3 presents the results of the logistic regression analyses conducted to assess the influence of sex and years in practice on secondary prevention practices. After controlling for differences in years of practice, we found that sex remained a significant predictor of the likelihood that respondents were in the action stage with regard to all five secondary prevention practice variables. Female dentists reported a significantly greater likelihood of being in the maintenance stage than male dentists. Number of years in practice was a significant predictor of both referring patients suspected of having an eating disorder and communicating with the patient’s primary care provider, although the observed odds ratios (ORs) indicate that years in practice was a marginal predictor (OR = 1.044 [confidence limits = 1.016, 1.073] and OR = 1.039 [confidence limits = 1.009, 1.070], respectively). Although statistically significant, years in practice does not appear to be substantively significant.

	DISCUSSION

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Because of the early oral signs of eating disorders, the dentist’s role in secondary prevention of these disorders is vital in reducing the likelihood of further damage to the oral cavity, the development of systemic health problems and premature death. Although the dentist’s role in assessing oral signs and symptoms of systemic health issues has been well-established, few studies have reported findings with regard to eating disorders. The purpose of this study was to assess sex differences concerning secondary prevention behaviors among dentists. In addition, we explored differences between male and female dentists with regard to behavioral beliefs about prevention practices.

Low level of practice. Results of this study indicate an overall low level of practice with regard to secondary prevention of eating disorders. Thirty-one percent of study participants reported that they did not assess patients for oral signs of eating disorders and did not plan to do so in the future (precontemplation stage), while 28 percent responded that they did not provide home dental care instructions to patients suspected of having an eating disorder and did not plan to do so in the future. In addition, approximately 48 percent of the study participants reported that they did not refer patients who exhibited oral sign of eating disorders, and they did not plan to do so. Approximately 53 percent of respondents indicated that they did not plan to communicate with their patients’ primary care providers.

These results are similar to those of DiGioacchino and colleagues¹⁸ in that 39 percent of dentists in that study indicated that they were not assessing dental patients for oral signs of eating disorders or providing specific home dental care instructions, and 50 percent indicated they were not referring for treatment patients who exhibited oral signs of eating disorders. However, the results of our study did differ from those of DiGioacchino and colleagues¹⁸ in that 67 percent of dentists in the latter study indicated that they were not communicating with their patients’ primary care providers (and did not plan to do so), while approximately 53 percent of dentists in our study reported that they were not communicating with their patients’ primary care providers or planning to do so in the future.

Dissonance between beliefs and behavior. An additional finding of interest concerns the dissonance observed among dentists with regard to reported high levels of perceived benefits of prevention practices and self-efficacy and the modest number of dentists currently engaged in secondary prevention practices. It seems to us that if one perceives secondary prevention behaviors to be beneficial and is confident in his or her ability to perform these behaviors, then he or she would be more likely to practice such behaviors. However, the results of our study show that while 91 percent of dentists perceived secondary prevention behaviors to be beneficial and 83 percent reported high perceived self-efficacy with regard to the behaviors, few reported actually having practiced prevention behaviors for more than six months. Further research is needed to identify variables influencing this dissonance.

Most noteworthy is the finding that more female dentists reported that they engaged in prevention practices than their male counterparts. This study revealed that more female dentists are assessing patients for oral manifestations of eating disorders, providing specific dental care instructions and referring patients who exhibit orodental signs of eating disorders. These findings may be explained, in part, by the differences observed with regard to prevention beliefs. For example, although the majority of male and female dentists reported that they perceive secondary prevention to be beneficial and reported high levels of perceived self-efficacy, we found significant differences concerning predisposing motivational factors when controlling for number of years in practice. The results show that female dentists perceived anorexia nervosa and bulimia nervosa to be more severe medical conditions than did male dentists. These perceptions may influence dentists’ motivation to engage in prevention practices.

Results of this study suggest that some characteristics associated directly with sex (such as female dentists’ greater tendency to refer patients)—rather than the fact that female dentists averaged fewer years in practice than male dentists—may be more associated with knowledge of oral and physical signs of eating disorders and health beliefs regarding the severity of eating disorders. Thus, these sex differences may influence dentists’ behaviors regarding the secondary prevention of eating disorders.

Potential mediating factors. Two potential mediating factors influenced the number of female dentists who reported a greater perceived severity of eating disorders and greater knowledge regarding the disorders’ oral and physical cues. One was sex differences with regard to sources of knowledge and frequency of exposure to information about anorexia nervosa and bulimia nervosa; the other was personal involvement, either with someone who had experienced an eating disorder or as an informal caregiver for a friend or family member experiencing anorexia nervosa or bulimia nervosa. Because eating disorders are more prevalent in women than in men, the differences in secondary prevention practices may be influenced by the relevance of this illness to women. Female dentists may be more sensitive to oral manifestations of systemic health problems related to women’s health issues. Further research is warranted to explore the mediating factors that affect male and female dentists’ decisions about whether to include secondary prevention practices in their clinical practices.

Study limitations. One of the study limitations is the cross-sectional design, which provides data that are descriptive in nature. The inclusion of subjects who are members of the American Dental Association and the American Association of Women Dentists excludes dentists who are not members (and who may differ in some respects from members). In addition, limiting subjects to those who identified themselves as general dentists further limits the generalizability of these findings. However, the random selection of participants and large study size may decrease the potential bias and increase the potential reliability of descriptive findings.

	CONCLUSION

TOP ABSTRACT SECONDARY PREVENTION PRACTICES SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The dentist’s role in identifying oral manifestations linked to systemic health issues is crucial in the secondary prevention of eating disorders. This study found that although dentists reported a low level of engagement in secondary prevention practices, more female dentists than male dentists reported that they assessed patients for oral manifestations of eating disorders, provided patient-specific home dental care instructions and referred patients with oral manifestations of eating disorders to physicians and other health care providers. To increase the number of dentists who are engaged in secondary prevention practices with regard to eating disorders, further research is needed to explore mediating variables of practice behaviors for male and female dentists.