Assessing Knowledge Gaps and Referral Practices in Pediatric Malocclusion Etiology: A Cross-Sectional E-Survey of Pediatricians and Family Physicians in Croatia

Abstract

Objective: Malocclusion affects oral health and quality of life, emphasizing the critical need to assess the knowledge and practices of healthcare providers in the prevention and treatment of malocclusion. The aim of this cross-sectional study was to investigate the knowledge and practice of Croatian pediatricians and family physicians regarding malocclusion, its causes and its impact on children’s health. Methods: An online self-structured questionnaire with 34 closed-ended questions was distributed to pediatricians and general practitioners throughout Croatia. The questionnaire addressed demographic data, knowledge of the causes of malocclusion, impact on children’s health and referral practices. Data were summarized in descriptive statistics, and a generalized linear model (GLM) examined the relationships between knowledge, referral practices and sociodemographic factors (p < 0.05). Results: Of 446 participants, including 364 general practitioners and 82 pediatricians (77.8% women), the mean knowledge score was 12.77 ± 3.41 out of 18, with 54.9% scoring at or above the median (Md = 13.00). Pediatricians had a higher mean score (13.77 ± 1.19) than family physicians (12.54 ± 3.60, p = 0.042). A higher level of knowledge was found among physicians working in community health centers (p ≤ 0.001) and among those recommending orthodontic examinations (p = 0.042). Over 90% of pediatricians and family physicians recognized hereditary factors, pacifier use, thumb and finger sucking, bottle feeding, trauma and accidents as causes of malocclusion. In addition, over 80% of respondents reported informing parents about harmful habits that can lead to misaligned teeth, with 100% of pediatricians giving such advice. Conclusions: Pediatricians have better knowledge about malocclusion compared to family physicians, and physicians in community health centers have the highest level of knowledge. It is recommended to improve the training of general practitioners and to promote early orthodontic examinations to improve preventive care.

1. Introduction

Malocclusion is an irregularity in the alignment of the teeth or the relationship between the maxillary and mandibular teeth during occlusion that deviates from the norm [1]. An ideal occlusion is characterized by a correct relationship between the upper and lower teeth without crowding, spacing, rotation or tilting. Normal occlusion is found in about 30% to 40% of the population [2]. According to the World Health Organization (WHO), malocclusion is the third most common oral health problem. Orthodontic problems associated with malocclusion can impair essential oral functions such as chewing, swallowing and speaking [1]. In addition to these functional problems, malocclusion can have a negative impact on dentofacial aesthetics and psychosocial self-confidence, resulting in a reduced quality of life [3].

The etiology of malocclusion is often complex and involves various anatomical structures such as teeth, bone tissue and neuromuscular components. It is not uncommon for multiple etiologic factors to coexist in one patient [4]. Typically, malocclusion is divided into intrinsic and extrinsic factors. Intrinsic or hereditary factors include abnormalities in the number, shape and size of teeth. Extrinsic factors include malnutrition, harmful oral habits (e.g., mouth breathing, thumb sucking, nail biting), trauma, accidents, ankylosis, caries and the early loss or retention of deciduous teeth. The loss of both deciduous and permanent teeth can exacerbate malocclusion, and caries can affect the growth of adjacent permanent teeth. Therefore, a comprehensive evaluation of these causative factors is crucial for accurate and effective treatment [5].

Healthcare providers play a critical role in the prevention and early intervention of malocclusion [2,6]. During routine childhood check-ups, pediatricians and general practitioners have the opportunity to educate parents about proper oral hygiene and the prevention of harmful habits that contribute to malocclusion, such as thumb sucking and prolonged pacifier use [7]. Malocclusion can impact the development of the temporomandibular joint and affect oral health, functionality and appearance, with these effects worsening as children grow [3]. Early detection and timely referrals to dentists can significantly improve treatment outcomes, potentially preventing the need for extensive orthodontic treatment. Physicians should integrate dental assessments into routine examinations to identify signs of malocclusion, such as crowded or misaligned teeth, abnormal spacing or jaw misalignment, allowing for prompt intervention. Collaboration between medical and dental professionals is essential for developing preventive strategies, ensuring continuity of care and improving children’s overall oral health and well-being [7,8,9,10,11].

Research on the familiarity of physicians and pediatricians with the etiological factors of malocclusion is limited, yet existing studies highlight important trends in their knowledge and referral practices [9,12,13,14,15,16]. Both groups often demonstrate limited understanding of children’s oral health, with pediatricians showing slightly better awareness due to their focus on child development [17]. However, many healthcare practitioners lack in-depth knowledge, leading to inconsistent referral practices [15,17,18]. While some recommend dental consultations, others delay referrals until problems are apparent, missing critical opportunities for early intervention [6,19]. Additionally, healthcare providers often fail to educate parents on preventing harmful oral habits, such as thumb sucking and prolonged pacifier use, which contribute to malocclusion [7]. Barriers to effective practice include inadequate orthodontic training, time constraints during consultations and insufficient collaboration between medical and dental professionals. Enhancing education and fostering interdisciplinary collaboration are essential for improving early orthodontic referrals, ultimately benefiting children’s dental health and overall well-being [20].

To date, no study has been conducted on this topic among pediatricians and family physicians in Croatia. Therefore, the purpose of this cross-sectional study, based on a questionnaire, was to assess the knowledge and practices of pediatricians and family physicians regarding malocclusion and the impact of malocclusion on children’s well-being and evaluate the impact of sociodemographic factors on their knowledge. It was hypothesized that the respondents would not demonstrate a satisfactory level of knowledge or appropriate practices related to referring pediatric patients for orthodontic evaluations aimed at preventing malocclusion.

2. Materials and Methods

2.1. Study Design and Setting

This cross-sectional survey was conducted at the Department of Restorative Dental Medicine and Endodontics, School of Medicine, University of Split, from January to March 2023. The study received ethical approval from the Ethics Committee of the Faculty of Medicine, University of Split. The study was based on a self-designed online questionnaire and the research adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [21,22]. Before starting the questionnaire, the participants were informed that their answers would be anonymous and voluntary. They were informed that they could withdraw from the study at any time without providing a reason. Participants received no compensation for their participation in the study. To complete the survey, participants had to answer all questions and click the “Submit” button to ensure that their answers were recorded; by completing the questionnaire, they agreed to participate. No identifying information was collected in the survey other than details of education, years of service, gender and workplace.

2.2. Participants

The questionnaire was developed and administered using the Google Forms^® platform (Google, Mountain View, CA, USA). A link to the survey was sent to the participants via the official email addresses on the websites of health centers in all districts of Croatia. The study used a non-probabilistic sampling approach and focused on family physicians (general practitioners) and pediatricians working in primary care throughout Croatia. The survey was sent to 1200 email addresses, and participants were encouraged to use the snowball method to expand the distribution to more colleagues. The survey was distributed directly to participants without formal advertising or promotion. The questions in the survey were presented in a continuous format, with each question displayed one below the other.

Inclusion criteria for the study included at least one year of clinical experience with children, current employment in primary health care in Croatia and completion of the questionnaire. Exclusion criteria were as follows: unwillingness to participate, incomplete responses, retired physicians, less than one year of clinical experience and physicians not currently working. Exclusion criteria included the following: unwillingness to participate, incomplete questionnaires, retired physicians, less than one year of clinical experience, physicians not actively working in primary health care in Croatia and not completing the questionnaire.

According to data from 2021, there were 2616 health teams working in family medicine (general medicine) and pediatrics in Croatia, including 2333 family physicians and 283 pediatricians [23]. The required sample size for the study, calculated with a 95% confidence interval and a 5% margin of error, was set at 330 GPs and 164 pediatricians. If the total population is considered, a sample size of 336 physicians and pediatricians would be sufficient as an alternative. This calculation was performed using the Sample Size Calculator (Raosoft, Inc., Seattle, WA, USA) [24].

2.3. Questionnaire

A self-report questionnaire was designed based on methods and frameworks from similar studies [9,12,13,14,15,16,17]. It was developed in collaboration between restorative and endodontic specialists and dental students. The questionnaire, which took approximately 10 min to complete, was divided into four sections and contained 34 closed-ended questions. To ensure clarity and efficacy, a pilot study was conducted with 15 participants who were subsequently excluded from the final data analysis. Following the pilot study, feedback was sought from participants on the clarity of the questions and any difficulties they had encountered. Based on this feedback, several changes were made to improve the wording and structure of certain questions and increase their clarity. The reliability of the questionnaire was assessed using Cronbach’s alpha (α), yielding a value of 0.814 for the knowledge section, indicating acceptable internal consistency. To further strengthen content validity, the questionnaire was reviewed by a specialist in pediatric dentistry, who assessed the relevance and importance of the individual items. The expert made suggestions for refining the questionnaire, including adjusting certain items to better reflect the critical aspects of knowledge, attitudes and practices related to orthodontic issues. Their feedback resulted in minor adjustments to improve the clarity and logical flow of the questions and to ensure that the questionnaire accurately captures the key elements relevant to healthcare professionals.

The first part of the questionnaire consisted of eight questions (Q1–Q8) on demographics and professional background, including age, gender, educational background, specialty, workplace, years of professional experience, average number of hours working with patients per week and the number of pediatric patients seen daily. The second part included 14 questions (Q9–Q22) that focused on the factors thought to contribute to malocclusion. The third part included four questions (Q23–Q26) on the impact of malocclusion on a child’s life, including the impact on oral symptoms, functionality, social interactions, esthetic concerns and emotional well-being. The answers in these sections were categorized as “Yes”, “No” or “I don’t know”. A scoring system was used where a correct answer (“Yes”) was scored as one and an incorrect answer was scored as zero. The total score for each respondent was calculated based on the number of correct answers, which is a quantitative measure of knowledge (maximum score was 18 points). The fourth section of eight questions (Q27–Q34) assessed respondents’ practices related to preventive measures for harmful oral habits and prevention of malocclusion and referral to orthodontists. This section addressed the recommended age for a child’s first orthodontic visit, the recommended duration of breastfeeding, and whether respondents inform parents about the effects of harmful oral habits such as thumb sucking and pacifier use.

The questions used in this study were part of a broader research project conducted with the same sample population and covering similar topics. The original questionnaire consisted of 65 questions designed to cover the research aspects comprehensively, some of which have already been used in a previous academic paper [17]. Due to the scope of the topic and the limited length of the publication, questions relevant to the objectives of this study were selected to enable a focused analysis while maintaining methodological precision and matching the scope of the publication.

2.4. Data Analysis

Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS), version 26 (IBM Corp., Armonk, NY, USA). The significance level for all statistical tests was set at 0.05. The Kolmogorov–Smirnov test was used to assess the normality of the data distribution. Descriptive statistics summarized the data, with categorical variables presented as frequencies and percentages, while quantitative variables were presented as means with standard deviations for normally distributed data or medians with interquartile ranges for non-normally distributed data. Statistical analyses were conducted using Pearson’s chi-square. A generalized linear model (GLM) was used to examine the associations between knowledge of etiological factors of malocclusion and its impact on children’s health, participants’ self-reported practices regarding referrals for orthodontic examinations and prevention of harmful habits and sociodemographic data. The factors considered in the generalized linear model included sex, age group, academic qualification, type of healthcare practice, years of clinical experience, conducting oral examinations, profession, daily hours spent on patient care, the number of pediatric patients seen daily, advising parents about harmful oral habits and referring for orthodontic examinations.

3. Results

A total of 446 respondents participated in the study, including 364 general practitioners (family physicians) and 82 pediatric specialists working in primary health care. Of the participants, 77.8% were women. The mean age of all participants was 43.9 ± 12.3 years (range: 26 to 67 years; median = 44.0; interquartile range = 33.0–54.0). Over three-quarters of the respondents worked in community health care practices and spent a maximum of eight hours daily with patients (

Table 1. Demographic and professional characteristics of study participants [17].

Characteristics		Family Physicians	Pediatricians	p-Value
Sex	Female	270 (74.2)	77 (94.0)	≤0.001 *
	Male	94 (25.8)	5 (6.0)
Age category (years)	<35	117 (32.0)	0 (0.0)	≤0.001 *
	35–44	98 (27.0)	22 (26.8)
	44–54	77 (21.2)	27 (32.2)
	>55	72 (19.8)	33 (40.0)
Academic background	DM	338 (92.8)	78 (95.1)	0.313
	MSc	16 (4.4)	4 (4.9)
	PhD	10 (2.8)	0 (0.0)
Types of health care settings	Community health center	290 (79.7)	57 (69.5)	0.046 *
	Private practice under concession	74 (20.3)	25 (30.5)
Years of clinical experience	1–5	96 (26.3)	14 (17.1)	0.036 *
	6–10	73 (20.1)	11 (13.4)
	11–20	96 (26.3)	23 (28.1)
	>20	99 (27.2)	34 (41.4)
Daily patient care hours	≤8	284 (78.1)	59 (72.0)	0.239
	>8	80 (21.9)	23 (28.0)
Daily pediatric patient visits	<10	263 (72.2)	0 (0.0)	≤0.001 *
	11–20	56 (15.3)	0 (0.0)
	21–50	14 (3.8)	26 (31.7)
	>50	31 (8.7)	56 (68.3)

Data are presented as whole number and percentage. * χ²—chi-square test or Fisher’s exact test, * p < 0.05.

) [17].

Table 2. Frequency of correct responses to questions on etiological factors of malocclusion and impact of malocclusion on children’s daily life and well-being.

Ethological Factors		Total	Family Physicians	Pediatricians	p-Value
Pacifier sucking	Correct answer	398 (89.2)	318 (87.4)	80 (97.6)	0.023 *
	Incorrect answer	48 (10.8)	46 (12.6)	2 (2.4)
Thumb and finger sucking	Correct answer	422 (94.6)	340 (93.4)	82 (100)	0.012 *
	Incorrect answer	24 (5.4)	24 (6.6)	0 (0.0)
Nail biting	Correct answer	253 (56.7)	209 (57.4)	44 (53.7)	0.540
	Incorrect answer	193 (43.3)	155 (42.6)	38 (46.3)
Lip and cheek biting	Correct answer	191 (42.6)	172 (47.3)	19 (23.2)	≤0.001 *
	Incorrect answer	255 (57.4)	192(57.2)	63 (76.8)
Bottle feeding	Correct answer	319 (71.5)	244 (67.0)	75 (91.5)	≤0.001 *
	Incorrect answer	127 (28.5)	120 (33.0)	7(8.5)
Respiratory abnormalities (mouth breathing, etc.)	Correct answer	184 (41.3)	127 (34.9)	57 (69.5)	≤0.001 *
	Incorrect answer	262 (58.7)	237(65.1)	25 (30.5)
Psychogenetics and bruxism	Correct answer	271 (60.8)	221 (60.7)	50 (61.0)	0.535
	Incorrect answer	175 (39.2)	143 (39.3)	32 (39.0)
Atypical (infantile) swallowing	Correct answer	98 (22.0)	76 (20.9)	22 (26.8)	0.152
	Incorrect answer	348 (78.0)	288 (79.1)	60 (73.2)
Trauma and accidents	Correct answer	410 (91.9)	333 (91.5)	77 (93.9)	0.319
	Incorrect answer	36 (8.1)	31 (7.5)	5 (6.1)
Dietary problems	Correct answer	180 (40.4)	138 (37.9)	42 (51.2)	0.019 *
	Incorrect answer	266 (59.6)	226 (62.1)	40 (48.8)
Premature loss of primary teeth	Correct answer	277 (62.1)	220 (60.4)	57 (69.6)	0.079
	Incorrect answer	169 (37.9)	144 (39.6)	25 (30.4)
Premature loss of permanent teeth	Correct answer	349 (78.2)	276 (75.9)	73 (89.0)	0.005 *
	Incorrect answer	97 (21.8)	88 (24.1)	9 (11.0)
Dental caries	Correct answer	222 (49.8)	176 (48.4)	46 (56.1)	0.126
	Incorrect answer	224 (50.2)	188 (51.6)	36 (43.9)
Heredity	Correct answer	416 (93.3)	334 (91.8)	82 (100)	0.002 *
	Incorrect answer	30 (6.7)	30 (7.2)	0 (0.0)
Oral symptoms	Correct answer	428 (96.0)	348 (95.6)	80 (97.6)	0.326
	Incorrect answer	18 (4.0)	16 (4.4)	2 (2.4)
Functional limitations	Correct answer	423 (94.8)	344 (94.5)	79 (96.3)	0.361
	Incorrect answer	23 (5.2)	20 (5.5)	3 (3.7)
Emotional and aesthetic well-being	Correct answer	430 (96.4)	348 (95.6)	82 (100)	0.036 *
	Incorrect answer	16 (3.6)	16 (4.4)	0 (0.0)
Social well-being	Correct answer	424 (95.1)	342 (94.0)	82 (100)	0.010 *
	Incorrect answer	22 (4.9)	22 (6.0)	0 (0.0)

Data are presented as whole number and percentage. Correct answer—“Yes”; incorrect answer—“No” and “I Do Not Know”. * χ²—chi-square test or Fisher’s exact test, df = 1, * p < 0.05.

presents the knowledge of family physicians and pediatricians regarding factors that contribute to malocclusion, and regarding the impact of malocclusion on a child’s life. For all the questions offered, the correct answer was “Yes”, while the incorrect answers were “No” and “I do not know”. In Supplementary Table S1, the distribution of responses “Yes”, “No” and “I do not know” are shown, while Table 2 presents the distribution of correct and incorrect answers. Over 90% of pediatricians were aware that hereditary factors, pacifier use, thumb and finger sucking, bottle feeding, trauma and accidents can lead to malocclusion. They most frequently associated pacifier sucking (89.2%), finger sucking (94.6%) and trauma (91.9%) with malocclusion. Additionally, more than 90% of family physicians correctly identified thumb and finger sucking, trauma, accidents and hereditary factors as contributors to malocclusion. However, fewer than half of the respondents recognized that caries, lip and cheek biting, respiratory abnormalities and dietary problems also contribute to these issues.

A large majority of respondents (over 90%) recognized that malocclusion affects the occurrence of oral symptoms, functional limitations, emotional and aesthetic well-being and social interactions. Pediatricians provided somewhat better responses compared to family physicians.

Table 3. Preventive measures implemented by healthcare providers for malocclusion and oral habits in pediatric patients.

Preventive Measures		Total	Family Physicians	Pediatricians	p-Value
Age at which children are referred for their first orthodontic treatment	3 years	106 (23.8)	83 (22.8)	23 (28.0)	0.020 *
	7 years	242 (54.3)	191 (52.5)	51 (62.2)
	9 years	79 (17.7)	71 (19.5)	8 (9.8)
	14 years	19 (4.3)	19 (5.2)	0 (0.0)
Advise parents about harmful oral habits	Yes	362 (81.2)	280 (76.9)	82 (100)	≤0.001 *
	No	84 (18.8)	84 (23.1)	0 (0.0)
Refer for orthodontic examinations	Yes	299 (67.0)	235 (64.6)	64 (78.0)	0.008 *
	No	147 (33.0)	129 (35.4)	18 (22.0)
Conducting oral examinations	Yes	376 (94.3)	299 (82.1)	77 (94.0)
	No	70 (15.7)	65 (17.9)	5 (6.0)
Recommended age for discontinuing breastfeeding	Up to 6 months	38 (8.5)	37 (10.2)	1 (1.2)	≤0.001 *
	Up to 1 year	215 (48.2)	183 (50.3)	32 (39.0)
	Up to 2 years	58 (13.0)	47 (12.9)	11 (13.4)
	While the child has a need	135 (30.3)	97 (26.6)	38 (46.3)
Recommended age for discontinuing pacifier use	6 months	200 (44.8)	162 (44.5)	38 (46.3)	0.012 *
	12 months	132 (29.6)	99 (27.2)	33 (40.2)
	18 months	39 (8.7)	33 (9.1)	6 (7.3)
	Do not recommend	75 (16.8)	70 (19.2)	5 (6.1)
Recommended age to discontinue bottle feeding	6 months	78 (17.5)	63 (17.3)	15 (18.3)	≤0.001 *
	12 months	220 (49.3)	160 (44.0)	60 (70.3)
	18 months	82 (18.4)	75 (20.6)	7 (8.5)
	Do not recommend	66 (14.8)	66 (18.1)	0 (0.0)
Recommended age for discontinuing thumb sucking	Time when all primary teeth have erupted (3 years)	109 (24.4)	95 (26.1)	14 (17.1)	0.231
	Time before permanent incisors have erupted (5–6 years)	25 (5.6)	19 (5.2)	6 (7.3)
	Should never be allowed	202 (45.3)	156 (42.9)	46 (56.1)
	No specific age	34 (7.6)	28 (7.7)	6 (7.3)
	Time after permanent incisors have erupted (8–9 years)	1 (0.2)	1 (0.3)	0 (0.0)
	Do not recommend	75 (16.8)	65 (17.9)	10 (12.2)

Data are presented as whole number and percentage. * χ²—chi-square test or Fisher’s exact test, * p < 0.05.

presents the preventive measures implemented by healthcare providers to address malocclusion and harmful oral habits in pediatric patients. Over 80% of respondents advise parents on harmful habits that may lead to malocclusion, with 100% of pediatricians providing such guidance. Half of the respondents recommend orthodontic evaluations starting at age 7. Most healthcare providers advise discontinuing breastfeeding and bottle feeding by the child’s first year (48.2% and 49.3%, respectively) and suggest ending pacifier use by 6 months (44.8%).

Table 4. Association between sociodemographic characteristics and knowledge of malocclusion etiology and impact on patients’ lives: generalized linear model analysis.

Characteristics		Total n (%)	OR (95% CI)	p-Value
Sex	Female	106 (23.8)	0.051 (−0.440–0.543)	0.838
	Male	242 (54.3)	Reference
Age category (years)	<35	79 (17.7)	Reference
	35–44	19 (4.3)	0.567 (−0.263–1.396)	0.181
	44–54	362 (81.2)	0.678 (−0.238–1.594)	0.147
	>55	84 (18.8)	0.312 (−0.635–1.259)	0.519
Academic background	DM	299 (67.0)	Reference
	MSc	147 (33.0)	−0.022 (−1.004–0.960)	0.965
	PhD	376 (94.3)	0.858 (−0.570–2.287)	0.239
Types of health care settings	Community health center	70 (15.7)	Reference
	Private practice under concession	38 (8.5)	−0.785 (−1.721–0.151)	≤0.001 *
Years of clinical experience	1–5	215 (48.2)	Reference
	6–10	58 (13.0)	−0.483 (−1.311–0.344)	0.252
	11–20	135 (30.3)	−1.007 (−1.918–−0.096)	0.030 *
	>20	200 (44.8)	−0.785 (−1.721–0.151)	0.100
Daily patient care hours	≤8	132 (29.6)	Reference
	>8	39 (8.7)	0.109 (−0.383–0.602)	0.663
Daily pediatric patient visits	<10	75 (16.8)	Reference
	11–20	78 (17.5)	−0.618 (−1.341–−0.018)	0.044 *
	21–50	220 (49.3)	−0.204 (−1.145–0.664)	0.603
	>50	82 (18.4)	−0.054 (−0.853–0.744)	0.894
Advise parents about harmful oral habits	Yes	66 (14.8)	0.323 (−0.266–0.912)	0.282
	No	109 (24.4)	Reference
Refer for orthodontic examinations	Yes	25 (5.6)	0.481 (0.018–0.944)	0.042 *
	No	202 (45.3)	Reference
Conducting oral examinations	Yes	34 (7.6)	0.453 (−0.106–1.013)	0.112
	No	1 (0.2)	Reference
Profession	Family physicians	75 (16.8)	Reference
	Pediatricians		0.843 (−1.156–0.308)	0.042 *

Reference knowledge or confidence level category is “low”. OR, odds ratio; 95% CI, 95% confidence interval (* p < 0.05).

presents the results of the generalized linear model analysis showing the differences in knowledge about the etiology of malocclusion across respondents’ sociodemographic factors, referral practices and professional roles. The mean knowledge score of all respondents was 12.77 ± 3.41 (Md = 13.00, IQR = 11.00–15.00, min = 0, max = 18), with more than half of the respondents (54.9%) scoring at or above the median. Family physicians had a mean score of 12.54 ± 3.60 (Md = 13.00, IQR = 11.00–15.00, min = 0, max = 18), while pediatricians had a higher mean score of 13.77 ± 1.19 (Md = 14.00, IQR = 12.00–15.00, min = 10, max = 18), with 72% of respondents scoring at or above the median.

Among the professional factors assessed, a higher level of knowledge was found among physicians working in community health centers (p ≤ 0.001), those recommending orthodontic examinations to their patients (p = 0.042) and pediatricians compared to general practitioners (p = 0.042). Additionally, lower levels of knowledge were associated with having 11–20 years of clinical experience (p = 0.030) and seeing 11–20 pediatric patients daily (p = 0.044), while factors such as sex, age group, academic qualifications, daily hours spent on patient care, advising parents about harmful oral habits and conducting oral examinations did not significantly affect knowledge (p > 0.05).

4. Discussion

The aim of this study was to assess the knowledge and practices of general practitioners and pediatricians regarding malocclusion, its risk factors and preventive measures. Proper and timely assessment of malocclusion and related factors in the primary dentition can significantly improve the prevention and treatment of occlusion-related problems throughout life [9]. There is also evidence that young children are more likely to visit a doctor’s office than a dentist’s office. Therefore, it is crucial for pediatricians to perform initial orthodontic examinations to detect anomalies early and make appropriate referrals [12]. Given their frequent contact with young patients, pediatricians have a unique opportunity to play a proactive role in early malocclusion detection and referral, which may otherwise be overlooked during routine dental visits.

The results indicate that pediatricians generally have a higher level of knowledge about malocclusion compared to general practitioners. This knowledge advantage of pediatricians is likely due to their focused training in child health and development, which includes dental topics such as malocclusion [9,13,25]. In addition, clinicians working in community health centers demonstrated greater knowledge, possibly due to having a broader range of patient interactions and more frequent exposure to cases requiring early detection and treatment of malocclusion. This suggests that clinical setting and the nature of patient interactions may influence the level of knowledge regarding malocclusion. However, the discrepancy in knowledge between pediatricians and family physicians suggests that family physicians could benefit from additional training or resources on malocclusion to improve their ability to effectively treat and prevent such conditions [17,19,26].

Both the pediatricians and family physicians demonstrated a keen awareness of the major factors contributing to malocclusion, including hereditary factors, pacifier use, thumb and finger sucking, bottle feeding, trauma and accidents. This reflects a good understanding of the critical factors involved in preventing malocclusion [5,9,27]. Our respondents, more specifically family physicians and pediatricians, predominantly cited pacifier sucking (89.2%), finger sucking (94.6%) and trauma (91.2%) as risk factors for malocclusion. However, some respondents underestimated the impact of other potential contributors, such as nail biting and mouth breathing, which suggests a need for more comprehensive education on the full range of malocclusion risk factors. This gap indicates that current training may not sufficiently cover risk factors that are less commonly recognized, potentially limiting practitioners’ ability to provide comprehensive preventive guidance.

In the study conducted by Arat et al., most respondents (86.1%) knew that bottle feeding can lead to malocclusion, as well as the fact that the use of a pacifier (81.5%) can lead to an open bite [9]. Koufatzidou’s study showed that almost all respondents (95%) believe that bad habits can lead to orthodontic problems [13]. Of the participants in the Indian study, 72% agreed that genetics is one of the most important etiologic factors for malocclusion, and 44% mentioned other causes of malocclusion such as malnutrition, premature loss of primary teeth and abnormal habits such as thumb sucking [8]. These findings align with our study’s results, reinforcing the notion that common risk factors are well-recognized across different regions, though awareness of specific etiologic contributors may vary.

Besides the fact that early orthodontic treatments help prevent further development of malocclusion, it also reduces plaque accumulation in individuals. Dentofacial anomalies may also lead to increased peer bullying among children and adolescents. In orthodontic literature, it has been reported that people experience ridicule because of their teeth and facial features. With early correction of malocclusions, children’s self-esteem may increase, and hence the probability of being bullied due to their teeth and jaw appearance may decrease [15]. Almost all participants of our research believe that malocclusion has a great impact on all aspects of a child’s life, such as through oral health (96%), emotional and aesthetic (96.4%) and social well-being (95.1%) and leading to functional limitations (94.8%). On the other hand, in the study by Premkumar and colleagues, only 22% of them agreed with the statement that child’s malocclusion not only affects their physical appearance but can also lead to a serious impact on the child’s psychological aspect [8]. This discrepancy may reflect differences in cultural perceptions of orthodontic issues, suggesting that awareness campaigns tailored to local contexts could enhance understanding of the broader implications of malocclusion.

Early diagnosis of orthodontic anomalies and timely referral to specialists are crucial for managing orthodontic issues effectively and lowering potential complications [15]. Our study found that a substantial proportion of general practitioners and family physicians (76.9%) and all pediatricians (100%) acknowledge the impact of harmful oral habits on children’s health. Additionally, three quarters of these practitioners recommend that parents consult an orthodontist, and more than a half of general and family physicians and also pediatricians are aware that the first orthodontic examination should ideally occur around the age of 7. This early intervention is critical for identifying and addressing malocclusion before it progresses, potentially reducing the need for more extensive and costly treatments later [15]. Despite the general awareness of early intervention, gaps in translating this knowledge into consistent practice suggest a need for clearer guidelines and training on referral processes.

However, while our findings demonstrate a good level of awareness about the importance of early orthodontic assessment and the benefits of timely referrals, there are notable variations in practice. For instance, a study from Iran reported that over half (55%) of family physicians recommend orthodontic evaluation when the first permanent tooth erupts [15]. Despite recognizing the role they play in the prevention and management of malocclusion, only 16% of these physicians effectively implement this knowledge in their daily practice. Similarly, an Indian survey found that while 92% of pediatricians acknowledged their critical role in recognizing and preventing malocclusion, only a small percentage (16%) effectively applied this knowledge in their routine practices [8]. These inconsistencies highlight barriers to implementing best practices, which could include time constraints, lack of resources or insufficient training on the importance of early referrals.

This study has several limitations that need to be considered. Firstly, the sample size is relatively small, which may limit the generalizability of the results to all pediatricians and GPs in Croatia. A larger and more diverse sample would be necessary to better represent the population and provide more robust conclusions. The cross-sectional design of the study provides a snapshot but does not take into account changes in knowledge, attitudes and practice over time. Future longitudinal studies could offer insights into how training, experience and evolving guidelines influence practitioners’ understanding and practices related to malocclusion. The use of a closed questionnaire may not fully capture the nuanced aspects of participants’ knowledge, attitudes and practices. Open-ended questions or mixed-method approaches could help capture a broader range of perspectives. Additionally, the sampling method, which relied on email addresses available on health center websites, introduces potential selection bias. Practitioners who maintain up-to-date contact information online may differ from those who do not, possibly influencing the study’s findings. Thus, important details could be overlooked. In addition, only physicians whose email addresses were available on health center websites were included in the study, which could lead to selection bias. Online self-assessment questionnaires may also present challenges in terms of respondent engagement and accuracy, which may affect the validity of the data collected. Additionally, the focus on whether pediatricians refer their patients to a pediatric dentist or orthodontist for orthodontic problems may not fully reflect the range of referral practices. Some participants may also refer patients to general dentists for preliminary evaluations, which might not have been captured in the questionnaire. This limitation suggests that the study may not completely represent the diversity in referral behaviors. This could influence the results, as referral to a dentist does not necessarily mean that the pediatrician does not provide consultation. In addition, the results of the study could be influenced by psychological, cultural or geographical factors that could affect the responses of individual participants. For example, cultural attitudes toward dental health and preventive care might shape practitioners’ practices and referral patterns differently in various regions. Future studies should consider exploring these factors to gain a more comprehensive understanding of the barriers and facilitators to optimal malocclusion management. Overall, while this study provides valuable insights into the knowledge and practices related to malocclusion among Croatian healthcare providers, these limitations should be taken into account when interpreting the results. Addressing these limitations in future research could improve the accuracy and applicability of findings in this field.

To improve knowledge and practice in relation to malocclusion, it is important to improve medical education with more comprehensive training on prevention and management. Both pediatricians and general practitioners should be specifically educated about harmful oral habits and the right time to stop them. Increased interdisciplinary collaboration between physicians and dentists can also promote better early diagnosis and prevention. Future research should focus on evaluating the effectiveness of these educational interventions and exploring the barriers to implementing preventive measures in clinical practice.

5. Conclusions

The study shows that both general practitioners and pediatricians have knowledge of the risk factors and effects of malocclusion on children’s health. Pediatricians show a higher level of understanding, likely due to their specialized training in child health, which increases their awareness of the impact of malocclusion on oral and overall well-being. However, significant knowledge gaps remain regarding effective preventive measures and the optimal time to stop harmful habits, highlighting the need for improved training in malocclusion prevention and management for all primary care providers.

In addition, our results show that referral practices vary widely, with many clinicians recognizing the importance of early orthodontic examination but not consistently implementing referral. This inconsistency suggests that additional training is needed to emphasize the importance of timely referral and to clarify referral guidelines. Improving curricula to include comprehensive guidelines on managing risk factors for malocclusion and practical training on referral timing could significantly improve outcomes.