|Year : 2020 | Volume
| Issue : 4 | Page : 629-635
|Factors influencing the periodontal referral behaviour of the general dental practitioners to a periodontist: A cross-sectional survey
Kanathur Smitha1, AR Pradeep2, Devaraj Anvitha3, Ishwar Pattar4
1 Department of Periodontology, Government Dental College and Research Institute, Bangalore, Karnataka, India
2 Department of Periodontology, Government Dental College and Research Institute; Oxford Dental College and Hospital, Bangalore, Karnataka, India
3 Department of Periodontology, Farooqia Dental College, Mysore, Karnataka, India
4 Community Health Centre, Nippani, Belgaum (Dist), Karnataka, India
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|Date of Submission||27-Jul-2018|
|Date of Decision||22-Mar-2019|
|Date of Acceptance||29-May-2019|
|Date of Web Publication||16-Oct-2020|
| Abstract|| |
Aim: In India, dental care scenario is unique and unequally available to the general population with both government-run hospitals and private dental clinics catering to the oral healthcare needs of the patients. There is lack of studies to address how periodontal diseases are managed in general dental practice in India. This study aimed to understand the periodontal referral patterns of general dental practitioners (GDP) to a periodontist in Karnataka state, India. Materials and Methods: This study employed a qualitative approach. Purposive samples of 400 referring dentists were interviewed using structured in-depth questionnaire. The questionnaire consists of a combination of selected response to the questions and close-ended questions, which was distributed to the GDPs of Karnataka state. Results: This survey shows deficient delivery of definitive periodontal treatment. Only 2% of the GDP reported that 80%–100% of their patients received scaling. Location of the practice appeared to have a major role in periodontal referral. Farther the location of the practice from district headquarters, poor was the referral. Clinical skill of the specialist appeared to have a major influence on the selection of specialist followed by academic qualification. Conclusion: This survey provides insight into the periodontal referral process by GDPs in India
Keywords: Comprehensive care, general dental practitioner, periodontal disease, periodontal treatment, periodontists, referral
|How to cite this article:|
Smitha K, Pradeep A R, Anvitha D, Pattar I. Factors influencing the periodontal referral behaviour of the general dental practitioners to a periodontist: A cross-sectional survey. Indian J Dent Res 2020;31:629-35
|How to cite this URL:|
Smitha K, Pradeep A R, Anvitha D, Pattar I. Factors influencing the periodontal referral behaviour of the general dental practitioners to a periodontist: A cross-sectional survey. Indian J Dent Res [serial online] 2020 [cited 2020 Oct 30];31:629-35. Available from: https://www.ijdr.in/text.asp?2020/31/4/629/298413
| Introduction|| |
Periodontal disease is one of the most common global healthcare problems and a major reason for tooth loss in adults with 80% or more adults experiencing periodontitis at some time during their lives and at least 20% having moderate to severe forms of periodontitis at any given time.
There is lack of reliable data on the prevalence of periodontal disease in India. Early “classic” periodontal epidemiological studies in India revealed high prevalence of periodontitis among the adults and economically weaker section of the society and considered India as the region of endemicity., Ramfjord et al. in their paper discuss about WHO survey done in India along with four other countries. They observed that there was 100% prevalence of periodontal disease in India. Dental Council of India, New Delhi, 2004 conducted National Oral Health Survey and Fluoride Mapping (2002–2003) and collected information covering various dimensions of oral health, including prevalence of oral health problems. This established reliable baseline data at the national and state levels. The results of survey showed that the prevalence of periodontal disease increased with age. The prevalence was 57%, 67.7%, 89.6%, and 79.9% in the age groups 12, 15, 35–44, and 65–74 years, respectively, with lower prevalence in older age (65–74 years) could be due to loss of teeth in the elderly. Moderate periodontitis was reported in 17.5% of the 35- to 44-year group and 21.4% in the 65- to 74-year group, whereas severe disease, defined as at least one tooth with ≥6 mm probing depth, was seen in 7.8% in the 35- to 44-year group and 18.1% in the 65- to 74-year group. No marked sex predilection was observed, and marginally higher prevalence was seen in rural subjects when compared with urban subjects. Those who had regular oral hygiene practice showed significantly reduced prevalence of periodontal disease, whereas use of toothbrush was found to be significantly better than finger cleaning.
The field of Periodontology has grown very rapidly in all dimensions in the last two decades and newer insights into existing concepts are changing the way periodontal diseases are managed. Over the last 2 decades, our understanding of the pathogenesis of periodontal disease, the potential relationship of periodontal disease to systemic diseases, and the generation of a variety of sophisticated treatment modalities has changed by leaps and bounds. Considering the high prevalence of periodontal disease, has the recent advances in Periodontology changed the scenario of how the periodontal duiseases are managed in general dental practice in India? There is lack of studies to address this aspect.
In India, dental care scenario is unique and unequally available to the general population with both government-run hospitals and private dental clinics and teaching dental colleges catering to the oral healthcare needs of the patients. India with its vast geographical area is divided into states, and there is diversity in culture, food habits, behavioral practices, and healthcare beliefs and also variation in socioeconomic and educational status. These factors may affect oral healthcare status. The protocol for management of periodontal disease in general dental practice has not changed in decades and exclusive periodontal specialty clinics are not available or very rare in India. Currently in India, the dentist to population ratio is 1:10,000 in urban areas and 1:20,000 in rural areas with unequal distribution. There is wide variation in the dental services available in urban and rural areas. Especially, in rural areas only basic dental treatments such as alleviating pain and extraction are available and sometimes even these procedures are also scarce. Lack of epidemiological data to identify the area needing oral health care and lack of government policies to tackle this problem may be the reason for this disparity in need and availability of the dental services.
General dental practitioners (GDP) in the private sector play an important role in the initial diagnosis and treatment of periodontal patients. The GDP's initially assess the periodontal status of the patients and refers them to consultant periodontist who visits their clinic. Many factors influence the decision to refer a patient for specialist care and support. Clinical, personal, and financial factors of the referring GDP and the specialist along with the patient's preferences and means make the referral process a complex entity in the everyday practice of dentistry. GDPs assess the periodontal status of patients, identify the risk factors, and make decisions to treat patients or refer them to a periodontist depending on their knowledge, attitude toward periodontal treatment, and their practices. There is little information available on this process. Many of the studies conducted in the area of referrals have attempted to analyze the psychodynamic aspects of the relationship between the referring GDP and specialist (periodontist). A study concluded that GDPs in the prime of their careers tended to be the best source of referrals for periodontists. Given the change over the last 2 decades in our understanding of the pathogenesis of periodontal disease, the potential relationship of periodontal disease to systemic diseases and the generation of a variety of sophisticated treatment modalities, it seemed logical to investigate whether these collective advances in knowledge have imparted periodontal referral patterns.
Cobb et al. found in a comparison of referral patterns between 1980 and 2000 that patients who were referred to periodontists from general dentists in 2000 exhibited a greater loss of teeth, had more severe periodontal disease, and required extraction of more teeth than did patients in 1980. Only a few studies have looked at the demographic factors influencing the referral relationship between GDPs and specialists., There are few reports in the dental literature regarding the types of periodontal services offered by GDPs. This study, by the means of a questionnaire, aims to identify the current status of periodontal treatment in dental clinics in India and was conducted with the following objectives: 1) to explore the demographic variables of the GDPs that may influence the patient referral to a periodontist, 2) to know the most frequently referred periodontal procedures for which dental practitioner seeks a periodontist, 3) to know the reasons for referring a patient to a periodontist, 4) to know the factors influencing the selection of a periodontist to whom they refer the patients, and 5) to know the periodontal procedures performed by a GDPs.
| Materials and Methods|| |
Study design and study population: A purposive sample of 400 GDPs (other than periodontists) was selected from different districts of Karnataka with equal representation from rural and urban areas.
The project has been approved by Institutional Ethical Review Board, Government Dental College and Research Institute, Bangalore (No. GDCRI/ACM/2014-15, Dated 25-11-2014). The questionnaire for this cross-sectional study was designed based on a literature review. A pilot study was conducted to pretest the questionnaire and to assure validity and reliability of the questionnaire. The questionnaire was then modified and presented as a series of 20 questions divided into four sections. The first section related to demographic factors, second section was about the factors influencing the choice of a periodontist for referral, third section was about procedures for which periodontal referral is done and fourth section was on the periodontal procedures performed by the GDPs. The questionnaire consists of a combination of selected response to the questions and close-ended questions. This questionnaire was distributed to the GDPs and requested to participate (January 2016 to June 2016). The subjects provided informed consent voluntarily to participate in the survey by signing in the covering letter provided along with the survey form.
Sample size: Currently in India, the dentist to population ratio is 1:10,000 in urban areas and 1:20,000 in rural areas. There are 30 districts in Karnataka with a population of 65.866,188 as per the census of 2016. Presuming that on an average there is one dental practitioner to 15,000 people (averaging the number of dentist in rural and urban areas), there are 4,390 dentists practicing in Karnataka and some of them may be periodontists among these practitioners. By random selection method, it was decided to include a minimum of 10% (4,000/10) as our target population, which makes 400 dental practitioners with equal representation from rural and urban areas. The data were tabulated on Microsoft excel spread sheet (2007). Descriptive statistics were used to provide a general overview of the findings. Each study participant was asked to rate the importance of variables on a five point Likert scale (1 = not important to 5 = very important).
| Results|| |
The study population included 61% (n = 244) male dentists and 39% (n = 156) female dentists. Out of this, 66% (n = 264; M - 140, F - 124) were only BDS (Bachelor of Dental surgery) qualified and 34% were MDS (n = 136; M - 104, F - 32) qualified (Postgraduation other than Periodontology) [Table 1].
Age-wise distribution of the study population appears in [Table 1]. About 46% of the study group were in the age group between 36 and 45 years and 39% were in the age group between 25 and 35 years. Together these two groups consisted 85% of the total study population which could be due to significant increase in the number of graduates in the last 2 decades.
Among the study population, 82% of the study population said they attended continued dental education program and received training to update their knowledge. Only 50% of the people who attended CDE program attended CDE programs related to Periodontics [Table 1]. About 69% of the subjects were members of Indian Dental association (IDA). About 45% were members of other speciality associations. Out of these, 19% were member of both IDA and other associations and 12% said that they were associated with none of the associations.
Geographic distribution of the study population appears in [[Figure 1 Suppl]. The number of years in practice is shown in [Table 2]. About 6% of the study population had <1 year of experience in practice, 21% of the study population had 1–5 years of practice, 27% of the study population had 6–10 years of experience in dental practice, 40% of the study population had 10–15 years of practice, and 6% of the study population had over 20 years of practice. Number of hours spent per week is shown in [Table 2]. About 79% of the subjects had solo practice. Out of these, 32% were specialists (other than periodontists). About 21% had group practice. Out of these, 14% were BDS qualified [Table 2].
Number of patients treated per week varied and [Table 2] shows the number of patients undergoing scaling. About 35% of the study population said they treated 1–5 patients/week with scaling, 27% said they treated 6–10 patients/week with scaling, and 23% said that they treated 10–20 patients/week with scaling. Only 13% said that they treated 21–40 patients/week with scaling, which was >50% of the total patients they treated/week and 2% of the study population said that they treated 41–60 patients/week, which was about 80% of the total patients treated/week. Periodontal procedures performed by GDPs are shown in [Table 2]. Most commonly performed procedure for periodontal treatment was scaling followed by periodontal maintenance [Figure 2 supple].
About 86% of the GDPs said that they refer the patients for periodontal treatment to periodontists and 14% did not refer the patients to any periodontists for periodontal treatment, which is shown in [Table 3] [Figure 1]. Periodontal procedures for which the help of periodontist is sought are shown in [Table 3] [Figure 2]. About 74% of the study population said that they referred their patients to a periodontist for the management of generalized periodontitis, followed by bone grafting, localized periodontitis, and soft tissue grafting in descending order. Factors influencing the choice of a specialist (periodontist) to whom the patients are referred is shown in [Table 3] [Figure 3]. Each study participant was asked to rate the 12 factors which may influence the selection of the periodontist to whom they refer on a five-point Likert scale (1 = not important to 5 = very important). Clinical skill followed by academic qualification was considered as important factor while considering for referring the patients to a periodontist. The number of patients receiving periodontal treatment by a periodontist varied with 55% saying that they referred up to two patients/month and 31% saying that they referred more than three patients in a month [Table 3].
| Discussion|| |
Healthy periodontal tissues are essential to overall dental and systemic health. Early diagnosis and timely management of the periodontal disease is essential in the successful management of dental patient and is an integral part of the general dental practice. While the importance of periodontal health is appreciated theoretically by most GDPs in India, the emphasis placed on periodontal health in general practice is largely unknown and the dynamics of periodontal referral pattern is unknown which may be due to the lack of data in the literature in the Indian scenario. This survey provides insight into the periodontal referral process by GDPs in India, periodontal procedures for which the referral is being made, the number of patients receiving the periodontal treatment in dental practice, and the factors that may influence the GDP's decision when deciding to whom to refer. This survey shows deficient delivery of definitive periodontal treatment. Only 10%–15% of the total number of patients receives oral prophylaxis. Only 2% of the GDP reported that 80%–100% of their patients received scaling and root planing. About 14% of the GDP never referred to a periodontist. Data analysis revealed that 75% of GDP who never made any periodontal referral practiced in rural areas away from district headquarters. When we enquired these GDPs for the reason for nonreferral, they told that periodontists were not available in their place of practice. These periodontists are also academicians working in dental college who are mostly located in the district headquarters and hence are based in district headquarters and not available in the rural areas. Remaining 25% said that some of the flap surgery to treat the periodontal pockets was taught in their undergraduate curriculum and they themselves managed. About 75% of the practitioners who said that they treated 21–40 patients, almost 50% of their patients with scaling were MDS qualified (other than periodontology). Additional qualification may have positive influence. The Rand health insurance experiment in 1970 suggested that periodontal conditions may have been undertreated in private practice with only 3% of the study population receiving scaling and root planing and an additional 3% receiving periodontal surgery. Although the speciality of Periodontology has grown in all dimensions, since that report in the last three decades, same is not reflected in the way periodontal diseases are managed in the private dental set up, especially in the Indian scenario.
Gender of the GDP did not appear to have an influence on the periodontal management or on the referral. Location of the practice appears to have major role in the periodontal referral. Farther the location of the practice from district headquarters, poor was the periodontal referral. About 14% of the GDPs did not make any referral. Even the initial periodontal treatment appeared to be inadequate. The accessibility of periodontist's services may have powerful effects on the decisions made by GDPs and patients in relation to periodontal referral. Attending CDE programs appeared to have positive effect on the periodontal management. The number of years in to clinical practice seems to have positive effect on the periodontal referral. Majority of the GDPs had 11–20 years of experience. There was greater variation in the number of hours spent in the clinical practice.
Even the size of the practice varied. Majority had solo practice. None of these appeared to influence the periodontal referral. Clinical skill of the periodontist appeared to have a major influence on the selection of periodontist followed by academic qualification and the previous positive experience between the patient and the consulting specialist appeared to have positive influence in that order. A cross-sectional online study involving GDPs practicing in the southern region of united states also reported that Periodontist's clinical skill was chosen by GDPs as the main factor influencing the periodontal referral.
Majority of them reported having referred 0–2 patients in a month, which only forms 1% of the patients which is grossly inadequate considering the high prevalence of moderate to severe periodontitis. Majority of them reported (74%) referring for generalized and localized periodontal disease, followed by regenerative and cosmetic periodontal plastic surgeries. Nonsurgical treatment comprising of scaling appears to be the major periodontal treatment given by GDP.
The efficient and timely delivery of periodontal treatment depends on the three factors, namely, knowledge, attitude, and practices of the practicing GDPs toward periodontal treatment, motivated patients who are aware of the importance of periodontal health, and on the availability of the committed periodontist. Awareness and motivation of the patients mostly depends again on the GDPs who initially examine the patients. With the increase in media exposure of the patients on the importance of oral health, patients are aware of the importance of the oral health, at least in the urban areas and they seek treatment. The most critical factor in the management of periodontal disease in general dental practice depends on the knowledge, attitude, and practices of the practicing dentist toward the importance of periodontal treatment. The GDPs first should be able to make early diagnosis of the periodontal condition, identify the patients requiring the periodontal treatment, motivate the patients on the importance of periodontal health, provide timely treatment to the patients according to their expertise, or refer them to a periodontist.
Periodontology is taught in the undergraduate curriculum in India in the pre-final and final year of their 4-year BDS course. They also undergo clinical training both in third year and final year as well as in internship. But, with this amount of clinical training, will they be able to make early diagnosis of the periodontal problems and provide timely treatment to the patients in clinical setup and put the theoretical knowledge into practice is a question mark. This preliminary survey aimed to assess the periodontal referral pattern in general dental practice. It lacked the instruments to assess the knowledge attitude and practices of the practicing dentist toward periodontal treatment, which is being addressed in an ongoing survey which may provide greater insight into the periodontal referral process.
This survey employed purposive sampling technique, a nonprobability sampling technique. The real issue with this technique of sampling is that the survey might have selected a particular population of dentist leaving another group and whether our study results could be generalized to the practitioners of India. Further, although we requested the participants to completely answer the questions, there was some missing data which is a limitation of this survey.
Chestnutt and Kinane suggest in their survey that “the management of periodontal disease has been overshadowed by more dramatic forms of dental activity. The provision of a restoration or denture appears to the uninformed patient as being of greater significance than the often intangible benefits of periodontal care.”  There is a need for multidisciplinary approach involving GDPs, medical professionals, periodontists, and other specialist to tackle periodontal disease. With regard to the dental profession, it is clear that there is a need to change the mindset and attitude of the dental educators, students, GDPs to understand the importance of appropriate periodontal management. Also, public must be educated to achieve global periodontal literacy which to certain extent can tackle the problem of deficient delivery of periodontal care and utilization of available services.
| Conclusion|| |
This study was undertaken to explore the factors that may affect the periodontal referral patterns of GDPs and to assess how GDP's perceptions of their knowledge for diagnosis and treatment of patients with periodontal disease affects their referral decisions. Within the limitations, this study shows deficient delivery of definitive periodontal treatment. Only 10%–15% of the total number of patients receives oral prophylaxis and only 2% of the GDP reported that 80%–100% of their patients received scaling and root planning. There is an urgent need of periodontal literacy among GDPs and public. The government should take effective measures and implement policies so that basic periodontal treatments are available to all.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Kanathur Smitha
Department of Periodontics, Government Dental College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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