Pediatrician’ Knowledge of the Importance of Stem Cells in Primary Teeth in Isfahan City

INTRODUCTION

Stem cells are kind of cells that have spontaneous reproduction and differentiation into at least two different types of cell [1]. The stem cells’ self-renewal potential makes them present in multiple cell division cycles while maintaining the ability to differentiate into and proliferate different adult cells types [2]. There are two types of stem cells: Adult Stem Cells (ASCs) and Embryonic Stem Cells (ESCs).

In general, embryonic stem cells are derived from a 4 or 5-day-old embryos (the blastocyst stage), and becausing accessing these cells requires that the fetus is removed, their acquisition is morally controversial [3]. The embryonic stem cells are the most powerful stem cells that are highly able to proliferate and differentiate [4]. However, these cells have possible neoplastic changes if the differentiation and proliferation of these cells are not well controlled. Adult stem cells do not need to destroy the fetus. They are successfully used for the treatment of diseases even though they are less capable than their fetal counterparts [5]. Some sources of ASCs include amniotic fluid, umbilical cord blood, skin, brain, urine, bone marrow, and teeth [6, 7]. Dental stem cells (DSCs) that are derived from the dental structure, especially dental pulp, are one of the adult stem cells, which can be obtained by minimally invasive methods [8, 9]. In 2000, dental pulp stem cells (DPSCs) were first discovered by Songtaoshi and Stan Gvanthos in the pulp of impacted third molar teeth [6]. Afterwards, the shi group obtained other dental stem cells types from the Stem Cells from Human Exfoliated Deciduous Teeth (SHED) [10], Stem Cells from Apical Papilla (SCAP) [11], and Supernumerary Tooth-derived Stem Cells (SNTSCs) [12].

According to recent studies, the dental pulp-derived stem cells have characteristics like high proliferative activity [13], self-renewal ability [13, 14], and multipotency as well as the ability to renovate the tissue, including dentin/pulp complex reconstruction [6, 11], reconstruction of root [12], and osteoporosis [15, 16]. These cells can also be used for the treatment of diseases such as Alzheimer's [17] and Parkinson's [18], regeneration of motor function in spinal cord injuries [19], improvement of neurological symptoms in patients with stroke [20], treatment of autoimmune diseases such as lupus systemic erythematosus [21, 22], and treatment of bone diseases such as early stages of menopausal osteoporosis [23], liver diseases such as liver cirrhosis [24], type 1 diabetes [25], and cardiac ischemia [26].

Since stem cells maintain their differentiation ability after freezing and melting, banking these cells is useful for future therapies. Hence, several banks have been established in the world [27, 28]. On the other hand, there are several challenges to the use of stem cells in society, and the opponents and supporters of this domain have their particular attitudes [29].

Unfortunately, most studies have shown that a lack of information and education about the potential of stem cells in the treatment of several types of diseases, which cause the loss of millions of primary teeth rather than saving them for future use. Pediatricians, Dentists, and other community health professionals deal with this and so, they should inform their patients about primary teeth maintenance.

Sede et al. [30] investigated the use of dermatologic stem cells in 200 Nigerian dentists. They showed that despite the high awareness of Nigerian dentists, they had poor knowledge about using stem cells. In 2014, Rohan Bhatt et al. [31] assessed the awareness of undergraduate dental students about the clinical application of dental pulp stem cells in Ahmedabad and Kandahar. Their results showed that most students did not know about the use of primary teeth as the source of stem cells. 84.44% of the students believed that dental stem cells were the best source for therapeutic use, while 30% of them believed that bone marrow or umbilical cord stem cells were the best sources. In 2015 Ankita Goyal et al. [32] did a similar study on Indian general dentists and specialists. They generally evaluated the knowledge and attitude of stem cell application in dentistry and indicated that there is a positive attitude toward the use of stem cells in dentistry. The type of educational degree and work experience had a positive role in the level of knowledge and attitude, but in the case of knowledge, their study showed that the educational degree (theoretical information) had a more effective role than the work experience (experience). In 2016, Norbakhsh et al. [33] carried out a study on 308 general dentists and 82 periodontists in Isfahan and revealed the participants had insufficient knowledge of using stem cells despite their relatively good awareness and positive attitude.

Unfortunately, many families who have not managed to keep their children's umbilical cord, do not keep the dental stem cells of their children due to a lack of knowledge about the ability of the stem cells of the primary teeth for curing many diseases. Therefore, it is important to inform various strata of society of the banking and storage of stem cells. Because pediatricians usually have a very close relationship with parents and children, and since there is no information about the knowledge and attitude of Iranian pediatricians about stem cells, including dental stem cells. This study aimed to determine the mean scores of attitude and knowledge of Iranian pediatricians about the importance of stem. The Zero hypothesis was inadequate attitude and knowledge of Isfahanese pediatricians about the importance of stem cells.

MATERIALS AND METHODS

The present study was a descriptive-analytic and cross-sectional study, based on designing a self-administered structured questionnaire with closed questions. This study was performed on 97 pediatricians in Isfahan. The mean score of knowledge and attitude was estimated with the maximum reliability of 95% and maximum error of 1. The criteria for involving in the study were pediatricians working in Isfahan who had informed consent to participate in the study. the exclusion criteria were questionnaires that were not completed by pediatricians for any reason. The ethics of accountability and cooperation of the relevant pediatricians were optional and all the information of the questionnaires were assessed completely confidential and tried to complete all stages with maximum accuracy and trust.
A sampling method was used to survey 97 of the 102 pediatricians in Isfahan. Sampling was done by referring to all private clinics or public hospitals in Isfahan in the fall 2015 and winter of 2016. The hours of referral were also considered between the two groups of pediatricians working in private clinics and working in hospitals to undermine the coherence and order of work. At this point, since most private clinics were more active in the afternoon, hours of referral were segregated and often the remaining hours were allocated to state clinics and hospitals.

Questionnaire

The data gathering tool in this study was a questionnaire containing 26 questions of single-answer packets in two fields of knowledge and attitude. It was structured in Persian language and published articles were used as the guideline for designing the questionnaire [30-33].

To confirm the face and content validity of the questionnaire, it was provided to five pediatricians of the Isfahan dentistry faculty. To validate the content, the questionnaire was delivered to each of the experts for an opinion poll. The experts were asked to answer each question in accordance with the following pattern of rating:

1. Question with a high degree of fit, 2. Question with the average degree of fit, 3. Question with a low degree of fit.

In addition, the experts were asked to comment on any of the questions if they had specific suggestions. After studying the results of the survey, the questions that were scored 2 or 3 were deleted or corrected according to the experts’ opinion.

The first questionnaire consisted of 17 questions for measuring knowledge and 16 questions for measuring attitude. After the study, 4 questions of knowledge and 3 questions of attitude were excluded and the final questionnaire consisted of 13 questions of knowledge and 13 questions of attitude. The questions were reinstated by experts. In the end, the opinions of the experts were obtained regarding the formal validity of the questionnaire.

In designing the attitude-oriented sentences, efforts were made to have the principles according to attitude-based questionnaires. For example, sentences were written to the present state as much as possible and were not in a way that provokes the answer.

The questions related to the level of knowledge and attitude of pediatricians working in Isfahan city about the stem cells based on Likert score were scored as follows:

Knowledge section "0 uninformed, 1 informed", the section of attitude "1 completely disagree, 2 disagree, 3 no opinion, 4 agree and 5 agree completely".

To assess and confirm the reliability of the questionnaires, a pilot questionnaire was distributed randomly among 20 pediatricians. The validity of the questionnaire was assessed by using the splite halfe method. According to the high correlation between the questionnaire (p = 0.002 and r = 0.7), the validity of the questionnaire was confirmed.

For the attitude section of the questionnaire, Cronbach's alpha was 0.72, which was acceptable according to the statistical consultant.

The final questionnaire consisted of three parts

Section one: These questions were about demographic information and were evaluated using 7 questions including age (in terms of age), gender (female/male), religion (Muslim / Christian / Jewish / other religions), work experience (<5, 10-5, 10 <), University and city that doctoral and postdoctoral degree were gotten from, University and city that they graduated in doctoral and postdoctoral degree, Year of graduation and finally the provision of the services of a pediatrician (private/public / teaching / other).

Part II: These questions included the scientific information of the pediatricians about the stem cells of primary teeth, which, at the first question, measured their information about the main subject of the study, and the next questions included the pediatrician's scientific information about the subject. An overview indicates the level of pediatrician awareness in this area. This section contained 13 questions with a minimum score of 0 and a maximum score of 13.

Part III: These questions included assessing the attitudes and points of view of the pediatrician, which revealed their ideological background. This section contained13 questions of 5 options (I totally disagree / disagree / disagree / agree / totally agree) with a minimum score of 13 and a maximum score of 65.

Statistic analysis

Data were fed into SPSS-22 software and analyzed by one-way ANOVA, t-test, Pearson correlation coefficient, Spearman, and Cronbach's alpha coefficient. The significance level was considered to be 0.05> α. Finally, after completing the data, the Cronbach's alpha for the knowledge part was calculated at 0/804 and was 0/861 for the attitude level.

RESULTS AND DISCUSSION

The purpose of this study was to determine the knowledge and attitude of Isfhanese pediatricians about the use of primary teeth stem cells. After collecting data, a questionnaire of statistical analysis was used in the form of descriptive and statistical method that was as follows presented:

A sample of 97 physicians working in Isfahan city, 52 were females (53.6%) and 45 were male (46.4%). The mean age of the sample was 48.0 ± 11.6, the mean age of women was 45.0 ± 10.10 and the mean age of men was 44.6 ± 11.8, respectively. Among the 97 pediatricians participating in the study, 90 (92.8%) were Muslim, 6 (6.6%) were Christian, and 1 (0.1%) was a follower of other religions. Of the 97 pediatricians, 18 (18.6%)had less than 5 years of experience, 16 (16.5%) had between 5 to 10 years and 63 (64.9%) had more than 10 years of experience.

Of the 97 pediatrics, 54 (55.7%) were graduated from Isfahan University, 18 (18.6%) were graduated from the University of Tehran and 25 (25.8) were graduated from other cities or abroad. Among postgraduate period: "54 (55.7%) were graduated from the University of Isfahan, 25 (25.8%) were graduated from the University of Tehran, 18 (18.6%) Graduated from other cities or abroad."

Of the 97 pediatricians, 23 pediatricians (23.7%) were graduated in 1993, 22 of them (22.7%) were graduated between 1994-2003, and 52 members (6.53%) were graduated between 2004-2015.

Among 97 pediatricians, 33 pediatricians (34%) were employed in private clinics and only 19 (19.6%) worked for public hospitals while 45 (46.4%) worked in different places.

The mean score of knowledge in the whole sample was 5.36 ± 3.15 based on 0-13 and the mean score of attitude was 48.13 ± 6.95 based on 13-65. The calculation of the Pearson correlation coefficient showed that there was a significant relationship between the mean score of knowledge and attitude (r = 0.330, P-value= 0.001).

The mean score of women knowledge was 5.75 ± 3.45 and was 4.91 ± 3.46 for men, and the mean score of attitude was 49.65 ± 7.17 for women and 46.77 ± 6.31 for men. T-test showed that there was no significant difference between the mean score of knowledge of women and men (P-value = 0.194). But there was a significant difference between the mean attitude score of the two sexes, which was higher for women (P-value = 0.002).

Pearson correlation coefficient showed that there is a negative and weak correlation between age and mean score of knowledge (r = -0.193, P-value = 0.05), but there was not a significant relationship between age and attitude (P-value = 0.061, r = -0.191). Also, this test showed that there was no significant relationship between the mean score of knowledge and experience of pediatricians (r = -0.308, P-value = 0.105). But there was a negative, inverse, and poor relation between the attitude and work experience of pediatricians (r = -0/217, P-value= 0.033) this test showed that there was not a significant relationship between the mean score of knowledge and attitude with the year that the pediatrician had been graduated (r = 0.089 P-value = 0.379) (r = 0.073, P-value=0.478).

One-way analysis of variance showed that there was a significant difference between the mean score of knowledge of those who received their general and special certificate from Tehran University, Isfahan, and other cities (P-value < 0.001, P-value = 0.045) However, there was no significant difference between the mean score of attitudes of graduates of general and specialized Ph.D. degrees from different universities (P-value = 0.961, P-value = 506) (Figure 1).

One-way analysis of variance showed that there was a significant difference between the mean score of the awareness of those who worked in the private clinic with those who worked in the public hospitals or pediatricians working in several places (P-value = 0.399). But, the LSD test showed that there was no significant difference between the mean score of knowledge of those who worked in the private clinic and those who worked in the public hospital (P-value = 0.940). But there was a significant difference between the average score of physicians working in private clinics and those who worked in several places, and this was higher for those who worked only in a private clinic (P-value = 0.026). Also, there was a significant difference between the mean score of those who worked in the hospital and those who worked in several places, which was higher for those who worked only in the hospital (P-value = 0.005).

T-test showed that there was a significant difference between the mean score of the awareness of those who received their information from watching television and those who had obtained their information from other sources, and this amount was significant for those who obtained information through sources rather than television (P-value = 0.37).

However, there was no significant difference between the average score of those who received their information from watching television and those who do not watch TV (P-value = 0.186). This test also showed that there was a significant difference between the mean score of the awareness of those attending the seminar and the scientific conference and those who did not participate, and this was higher for those who obtained their information through participation in seminars (P-value=0.003). However, there was no significant difference between the mean scores of attitudes of those attending the seminar and the scientific conference and those who did not participate (P-value = 0.803).

Figure 1 shows the distribution of the frequency of using different sources to obtain information about the stem cells of the teeth.

Tables 1 and 2 show the distribution of frequency of responses, mean, and standard deviation of the knowledge and attitude scores in terms of questions about using the stem.

Table 1. Frequency distribution of responses and comparison of mean score of responses on the application of stem cells in primary teeth

Table 2. Frequency distribution of responses, mean and standard deviation about the use of stem cells in primary teeth