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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 34-39

Pattern and frequency of periodontal referral by general dentists and other specialists in Davangere city


1 Private Practitioner, Mumbai, Maharashtra, India
2 Department of Periodontology, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Submission24-Dec-2020
Date of Acceptance01-Apr-2021
Date of Web Publication9-Aug-2021

Correspondence Address:
Dr. Rucha Shah
Department of Periodontology, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_39_20

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  Abstract 


Introduction: The present cross-sectional survey study conducted to assess the type of periodontal treatments being done by dental practitioners or specialist other than periodontists and to assess the types and frequency of cases being referred to the Periodontist in the city of Davangere, Karnataka state.
Materials and Methods: The proposed study was carried out by asking various dental practitioners other than periodontists to fill a structured questionnaire containing 7 questions focusing on several clinical and nonclinical periodontal scenarios, whether they would treat the patient in the office or refer/consult to a periodontist. A population of 64 was studied which comprised of 31 general dentists, 33 specialists and obtained data were then subjected to analysis.
Results: Most of the private practitioners (82.8%, 53/64) carry out nonsurgical periodontal therapy in their clinics. Among the surgical periodontal procedures, gingivectomy and gingivoplasty are the most commonly performed (40.65, 26/64) surgical periodontal therapy. Around 71.9% (46/64) of practitioners refer or consult their periodontists for the surgical periodontal procedures. Flap surgery is the most commonly performed procedure by the periodontist. The frequency of referring or consulting periodontist is more among dental specialists (P = 0.03). Majority of practitioners, i.e., 65.6% (42/64) feel that there are few patients with periodontal disease who get motivated for periodontal treatment whereas 42.2% (27/64) believe that cost-effectiveness of the periodontal treatment is responsible for such referral pattern.
Conclusion: It was concluded that our survey study shows that most of the dental practitioners in Davangere city carry out non-surgical periodontal therapy in their clinic and more than half of the dental practitioners refer or consult to their periodontists for surgical periodontal therapy. However, the frequency of referring or consulting the periodontist is low.

Keywords: Davangere city, periodontal practice, private practitioners, referral, survey


How to cite this article:
Pawar D, Thomas R, Shah R, Mehta DS. Pattern and frequency of periodontal referral by general dentists and other specialists in Davangere city. Int J Oral Health Sci 2021;11:34-9

How to cite this URL:
Pawar D, Thomas R, Shah R, Mehta DS. Pattern and frequency of periodontal referral by general dentists and other specialists in Davangere city. Int J Oral Health Sci [serial online] 2021 [cited 2021 Nov 28];11:34-9. Available from: https://www.ijohsjournal.org/text.asp?2021/11/1/34/323533




  Introduction Top


The field of dentistry is fast evolving with changing demography of patient population which is both health and cost conscious, hence, enhancing the scope of practice. People expect to maintain a functional and esthetically pleasing natural dentition throughout their life in comfort and health. The absence of proper management of the periodontal diseases results in its progression and eventual tooth loss.[1] Furthermore, emerging body of evidence shows periodontal disease as a significant risk factor for numerous systemic conditions.[2] Significant progress regarding the basic knowledge concerning periodontal microbes, disease and its pathogenesis has led to newer treatment protocols. However, lack of diagnostic skills, the assessment of severity particularly during early disease stages leads to under diagnosis of periodontal disease. Good clinical reasoning and decision making are necessary factors in the appropriate management of patients.[3]

In this changing scenario, general practitioners need to be well prepared to not only provide primary oral health care but also be well informed about when to treat and when to refer. This should be based on an honest appraisal of skill levels and preferences of treatment.[4] A cross-sectional survey among general dentists in Nova Scotia, Canada, concluded that dentists rendered nonsurgical periodontal therapy on a wide scale, whereas their involvement in oral or periodontal and implant surgical therapies was limited.[5] A recently survey conducted by United States National Dental Practice-Based Research Network conducted a classified orthodontics and periodontal surgery as “ most uncommon” dental procedures, rendered by general practitioners highlighting the big vacuum that exists regarding the rendition of these two services.[6]

A timely and appropriate referral to a periodontal practice is an important determinant in maintaining vitality of periodontal health. Studies have shown that delayed referral precludes specialists from the opportunity to salvage periodontally compromised teeth.[1],[3] Assessing the referral pattern helps gauge the implementation of methods for improving referrals, in a country. However, literature provides very limited data in this regard, especially in India. Thus, the present cross-sectional study was undertaken to assess the provision of periodontal care and profile of referral by general dental practitioners and other specialists to the periodontists in the city of Davangere.


  Materials and Methods Top


This was a cross-sectional survey carried out among the general dental practitioners and specialists other than periodontists in Davangere city. The study protocol was approved by the institutional ethical committee was carried in accordance with the declaration of Helsinki. Consent was taken as agreement to fill the questionnaires, which contained no personal identifiable responses. The survey form was distributed amongst general dental practitioners and specialists other than periodontists having dental clinic with experience of at least 1 year, who were actively engaged in private practice in the city of Davangere. House surgeons and dental students were excluded from the study. With the help of data collected from district health office, a list of 68 private dental practitioners was prepared. Among these, four were not included in the study as two were periodontists and two refused to participate in the study. Finally, a population of 64 was studied which comprised of 31 general dentists and 33 specialists including Orthodontists, Endodontists, Prosthodontists, Oral and Maxillofacial surgeon, Oral Pathologists, and Oral Medicine and Radiologists.

Ethical clearance for conducting the study was obtained from the Institutional Review board and Ethical Committee. The dentists were personally interviewed in their free time with prior appointment over phone. The investigator visited the clinic, appraised them about the study and administered a structured questionnaire containing 7 questions pertaining to their opinion about periodontal treatment, their ability to perform the same and the frequency of referral or consultation to the periodontists. The results were tabulated and subjected to statistical analysis (SPSS version 17.0). Chi-square test and Fischer's test were used to analyze the collected data.


  Results Top


A total of 68 questionnaires were distributed out of which 64 private practitioners responded with a response rate of 94.1%. All questionnaires were answered completely. Among these 31 (48.4%) were general dentists and 33 (51.5%) were specialists. A majority of 53 (82.8%) private practitioners stated that they carried out scaling and root planning in their clinics, out of which 29 (93.5%) were general dentists and 24 (72.7%) were specialists of other field, while 11 (17.2%) stated they referred patients for the same. The comparison between general dentists and specialists in terms of nonsurgical and surgical phase of therapy they carry out by themselves in their clinic is depicted in [Table 1].
Table 1: Comparison of general dentists and specialists according to the periodontal therapy they carry out in their clinic

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When questioned about their referral profile, 46 (71.9%) practitioners said they referred or consulted their periodontists for the surgical periodontal procedures of which 25 (75.8%) were specialists while 21 (67.7%) were general dentists. Among the practitioners, who were not referring or consulting their periodontists, 5 (7.8%) carried out surgical periodontal procedures by themselves whereas 8 (12.5%) practitioners said that they had very few patients of periodontal disease who get motivated for periodontal surgery. The frequency of referral or consultation was once a month for 27 (42.2%) whereas 4 (6.3%) and 8 (12.5%) for twice a week and once a week respectively. Around 17 (26.6%) responded that they refer or consult periodontists once in 3 or more months. The distribution of study subjects on the basis of signs and symptoms of patients for which they consulted a periodontist is shown in [Table 2].
Table 2: Comparison of general dentists and specialists on the basis of signs and symptoms of the patients they consulted a periodontist for

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The response for which kind of surgical periodontal procedure is carried out by the periodontists in the clinic is shown in [Table 3]. While assessing the practitioner's opinion regarding the results of periodontal treatment we found, that 61 practitioners thought that stoppage of bleeding occurred post treatment, among which 44 (77.2%) felt that it happens always and 17 (27.9%) felt that it occurs occasionally. Among the 60 who responded that elimination of pocket occurred, 30 (50%) felt it happened always whereas rest 50% felt it happens occasionally. Although 34 (55.7%) practitioners observed that there is always reduction in tooth mobility, 25 (41%) others sensed reduction in mobility occurs occasionally. In case of the option “increased life span of teeth” after periodontal treatment 36 (59%) practitioners felt that it happened always whereas 24 (39.3%) felt that it happens occasionally. Root coverage occurrence after periodontal treatment was always observed by 19 (40.4%) practitioners while 28 (59.6%) said that it occurred occasionally. Regarding recurrence of the disease 40 (87%) practitioners felt that it occurs occasionally, 4 (8.7%) felt always while 2 (4.3%) said no recurrence occurs after the periodontal treatment.
Table 3: Distribution of study subjects according to which surgical periodontal treatment is performed by their periodontist in their clinic

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Majority of practitioners, i. e., 42 (65.6%) feel that there are fewer patients with periodontal disease who get motivated for periodontal treatment whereas 27 (42.2%) believed that cost-ineffectiveness of the periodontal treatment affected the referral pattern. The next two most common causes given by 22 (34.4%) practitioners included the lack of patient's acceptance for being referred to another dentist while 18 (28%) practitioners felt that they could carry out most of the procedures by themselves. The least common reason cited by 10 (15%) participants was nonsatisfaction with the results of the periodontal treatment procedures.


  Discussion Top


Patient referral to specialist in dentistry creates a unique pattern of comprehensive dental care beneficial to all. Hence, to assess the pattern of referral to periodontists, we conducted this study in the city of Davangere. Private practitioners of the city of Davangere were surveyed using a concise instrument generated to answer the research questions as well as to promote a higher rate of response. The response rate for the survey was 94.1% (64/68). When asked regarding referral to periodontists for Phase I therapy, it was seen that, majority of them carried out nonsurgical periodontal therapy in their clinics. This was in accordance with previous surveys of periodontal services rendered by general dentists.[4],[5],[7],[8],[9],[10],[11] High awareness was observed amongst dental practitioners regarding demonstration of proper brushing techniques. However, surprisingly general practitioners were more particular about advising mouthwash than specialists, as the latter focused more on their area of expertise. Yet, less than one-third respondents advised diet counseling to their patients. Furthermore, only 50% respondents encouraged their patients to discontinue harmful habits, highlighting the lack of importance to behavioral interventions for tobacco cessation by oral health professionals. Around 47% of the dental practitioners accepted providing splinting as a treatment option to their patients. This finding is in contrast to survey done by Mali et al. who found more than two-third of the general dentists not using temporary or permanent splinting as an acceptable treatment modality in private dental clinics.[6]

In contrast to the response for nonsurgical periodontal therapy, the dental practitioners in this study reported providing periodontal surgical therapy to a much more extent. Gingivectomy and crown-lengthening procedures were the common surgical techniques performed by the respondents themselves. In the current study, 38% of the private practitioners reported performing crown lengthening procedures whereas 17% general dentists reported rendering this surgical service.[2],[4] Furthermore, gingivectomy and gingivoplasty were found to be the most common surgical periodontal procedure performed by the general dentist, a finding in congruence with the previous studies.[2],[4] Such regional variations in data, could be due to a number of nonpatient-related factors including differences in undergraduate education curriculum, distance from an established periodontal practice and whether the dentists had attended a postgraduate program. Data from the present survey reveal that dental practitioners are more involved in minor periodontal surgical procedures rather than advanced surgical procedures.

Almost one-third of the responders referred or consulted their patients to a periodontist for surgical treatment. This finding is in contrast with a previous study in which more than half of the general dentists were referring or consulting their patients for surgical periodontal procedures. In a 2015 study, younger dentists expressed low confidence about knowing when to refer, this could possibly explain the aforementioned result.[7] One interesting finding of the present study is that proportion of referring or consulting periodontist for surgical periodontal procedures is more among the specialists. When asked about the referral frequency, referring once in a week is more common in specialists and once in a month is more frequent among general dentists. This difference can be attributed to more knowledge and concern regarding the signs and symptoms as well as pathogenesis of periodontal disease among the specialists.

Out of the practitioners who were not referring or consulting the patients for the surgical periodontal procedures only 28% carried out surgical procedures themselves and showed interest in providing periodontal care in their own offices. 65% respondents had very few patients of periodontal disease who got motivated for periodontal surgery. General dentists and specialist both claimed to face, patient motivation problem to a similar extent. This finding can be attributed to painless progression of periodontal disease, lack of knowledge regarding the outcome of periodontal disease and reflects the low priority which these patients put on their dental health. Many dentists seemed to operate a form of triage in which they referred only those patients whom they believed were co-operative and would benefit from periodontal care. It is dentists who need to explain to patients the need for and the importance of periodontal treatment.

Almost half of the practitioners felt that poor cost effectiveness of the periodontal treatment is associated with low periodontal referral. Cost structure and methods of payment may differ in different cities and even in different areas of the same city. Such responses are not only associated with poor diagnosis but also insufficient knowledge amongst practitioners about the irrefutable link between periodontal disease and systemic health. For better patient motivation, awareness must be created about the strong impact presence of periodontal diseases has on a patient's systemic health. It is understandable that 35% patients refused the offer of referral probably because the personal reputation and skills appeared to be a greater determinant than the academic status of the specialist. In addition to making referrals based on the clinical condition of the patient, it has been found that many referrals are based on the relationship between the general practitioner and the periodontist and especially on the communication between these professionals. Unfortunately, a lack of communication between general practitioners and periodontists has been found to be a significant barrier to effective patient referrals.[8]

The cardinal sign of periodontal disease is considered to be the periodontal pocket and loss of attachment. In our study, we found that only one in every three general dentists surveyed referred patients to a periodontist based on the presence of pockets whereas proportion of specialists referring patients based on these criteria was more. It is interesting to note that, periodontal flap surgery is still the most commonly performed periodontal surgical procedure performed by the periodontist in dental clinics of Davangere.

When asked about the sign and symptoms for which practitioners referred patients to a specialist, it was observed that almost half the practitioners referred patients to a periodontist for the chief complaint of mobile teeth. Two fifth practitioners believed that reduction in mobility following periodontal treatment occurred occasionally. This finding gives us an indication that more awareness should be created in the respondents regarding flap surgery, along with bone grafting/guided tissue regeneration procedures which form the cornerstone of periodontal practice in general dental clinics. It was also observed that, less number of general dentists referred their patients to a periodontist for root coverage procedures compare to specialists. These data reveal lacunae in the knowledge of general dentists regarding esthetics and functional aspects of gingival recession and importance of attached gingiva. In addition, less than one-third general dentists and specialists considered implants as an integral aspect of periodontist's armor while the rest either occasionally or did not at all refer such cases to periodontists.

When asked about the success of the periodontal treatment, almost all the practitioners believed that there was cessation of bleeding, elimination of pocket, reduction in mobility and increased life span of teeth after the treatment. Two-thirds of practitioners responded that there is occasional recurrence after periodontal treatment, while <3% believed that there was no improvement in tooth mobility and life span of teeth. Thus overall, there is high level of satisfaction with the treatment of the most common periodontal complaints; however, lack of maintenance and awareness toward oral hygiene measures may be the chief factor for reported recurrence of periodontal disease. Thus, more emphasis needs to be laid upon development of simple but robust system to regularly monitor treatment progress in patients with mild periodontitis.

Data from the present survey reveal that practitioners prefer carrying out most of the periodontal procedures themselves and the referral profile is poor. 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.[9] Many times graduating dentists and students doing specialization in dentistry are burdened by significant student loans and also opening up a new practice is an enormously costly affair. This higher rate of debt could lead younger dentists to try and keep more patients in their own practice by adapting procedures that are repetitive, expensive, and often ineffective form of limited periodontal care which can alleviate patient's problems slightly but not completely.[11] It is not possible for them to deliver definitive periodontal therapy required to handle the patient's condition. Such patients, when referred, after several futile attempts present with a much worsened periodontal condition wherein they cannot be fully benefited from the services of a periodontist. Thus, the services of a periodontist are underestimated both by the patient and the general dentist.

As a periodontist, there is dependence on general dentists, first, to identify patients with periodontal needs, and second, to refer them at an appropriate time in their disease process. Over the years, various national organizations of different countries like the American Academy of Periodontology have attempted to facilitate this process through the creation of Parameters of Care, Guidelines for Periodontal Therapy, the Periodontal Screening and Recording program, and educational programs such as the Professional Partnership Program.[12],[13] These guidelines help the practitioner in triaging patients who currently have or who are at risk for the development of periodontal diseases. In India, ambiguity exists as no referral protocols are in place. Standard bodies like Indian dental association and Indian society of periodontology must understand the factors which influence clinical decisions and send recommendations to the Dental council of India so that guidelines for appropriate referral can be framed and variability ultimately be reduced.

Limitation of the present study is that in our study only general dentists from Davangere were recruited to participate in this study who had mostly graduated from dental colleges in the same state and hence their dental education concerning periodontal therapy and referrals would be similar. Furthermore, the general dentists self-reported the degrees to which patient factors or their own referral considerations affected their periodontal treatment decisions. These self-reports might be honest perceptions, but might not always objectively reflect reality.


  Conclusion Top


These results from the current study indicate that periodontal referral processes need to be re-analyzed to ensure that patients receive the best periodontal care available. The threat of delivering improper dental care looms large if course correction is not done at the earliest. We must work diligently to educate general practitioners through all possible avenues about correct diagnosis, optimal treatment and timely referral of periodontal diseases. Finally, it is desirable for future research to go beyond general dentists' self-reports of practice behavior and assess factors affecting referral processes more objectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jeffcoat M. When to treat: When to refer. Int Dent J 1993;43:185-91.  Back to cited text no. 1
    
2.
Ghiabi E, Matthews DC. Periodontal practice and referral profile of general dentists in Nova Scotia, Canada. J Can Dent Assoc 2012;78:c55.  Back to cited text no. 2
    
3.
Gilbert GH, Gordan VV, Korelitz JJ, Fellows JL, Meyerowitz C, Oates TW, et al. Provision of specific dental procedures by general dentists in the National Dental Practice-Based Research Network: Questionnaire findings. BMC Oral Health 2015;15:11.  Back to cited text no. 3
    
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Lanning SK, Best AM, Hunt RJ. Periodontal services rendered by general practitioners. J Periodontol 2007;78:823-32.  Back to cited text no. 4
    
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Robertson PB, del Aguila MA, Anderson MH. Trends in periodontal care. Periodontol 2000 2002;30:104-10.  Back to cited text no. 5
    
6.
Mali A, Mali R, Mehta H. Perception of general dental practitioners toward periodontal treatment: A survey. J Indian Soc Periodontol 2008;12:4-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Forbes. Current practice and factors influencing the provision of periodontal healthcare in primary dental care in Scotland: An explorative study. Br Dent J 218:387-91.  Back to cited text no. 7
    
8.
Kourkouta S, Darbar UR. An audit of the quality and content of periodontal referrals and the effect of implementing referral criteria. Prim Dent Care 2006;13:99-106.  Back to cited text no. 8
    
9.
Cobb CM, Carrara A, El-Annan E, Youngblood LA, Becker BE, Becker W, et al. Periodontal referral patterns, 1980 versus 2000: A preliminary study. J Periodontol 2003;74:1470-4.  Back to cited text no. 9
    
10.
American Dental Association. The 2005-06 Survey of Dental Services Rendered. 2007. p. 1-159.  Back to cited text no. 10
    
11.
Kumar A. Referral of a periodontal patient- when & why? J Oral Health Community Dent 2007;1:23-6.  Back to cited text no. 11
    
12.
American Academy of Periodontology. Parameters of care. J Periodontol 2000;71 Supp l: 847-8.  Back to cited text no. 12
    
13.
Greenwell H, Committee on Research, Science and Therapy American Academy of Periodontology. Position paper: Guidelines for periodontal therapy. J Periodontol 2001;72:1624-8.  Back to cited text no. 13
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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