|Year : 2018 | Volume
| Issue : 1 | Page : 62-71
Knowledge of diagnosis, treatment strategies, and opinions on periodontal treatment procedures among general dentists in an Indian urban population: A questionnaire survey
Priya Sathyamurthy, Ashvini Padhye, Himani Swatantrakumar Gupta
Department of Periodontics, Mahatma Gandhi Mission's Dental College and Hospital, Mumbai; Department of Periodontics, Maharashtra University of Health Sciences, Nashik, Maharashtra, India
|Date of Submission||31-Jul-2017|
|Date of Acceptance||28-Dec-2017|
|Date of Web Publication||23-Mar-2018|
Dr. Priya Sathyamurthy
Mahatma Gandhi Mission's Dental College, Junction of NH4 and Sion-Panvel Expressway, Sector 1, Kamothe, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: A greater proportion of general dentists are unaware of the basic periodontal treatment needs as evidenced by the documented rise in advanced periodontal diseases culminating in tooth loss. Furthermore, limited data exist regarding the demographic predictors of referral for the specialty of periodontics. Therefore, the aim of the survey was to explore and evaluate the knowledge of diagnosis, treatment strategies, and opinions of general dentists on periodontal treatment procedures. Methods: This was a pilot survey utilizing a self-administered close-ended questionnaire consisting of 18 questions undertaken for 100 general dentists with a Bachelor of Dental Surgery degree. The questions were divided under 3 domains assessing the diagnosing ability, the treatment planning skills, and the dentists' perception of periodontal treatment outcomes. Based on their experience, the survey population was divided under three groups; Group I (n = 17) with <5 years of experience, Group II (n = 42) with 5 to <10 years of experience, and Group III (n = 33) with ≥10 years of practice. Pearson's correlation coefficient test was used to identify any significant associations between the responses. Results: On an average, 64.7% of correct responses were noted. About 95.7% of general dentists agreed that they performed complete scaling for all patients. Nearly 85.9% felt that there were higher chances for the recurrence of periodontal diseases and opted to retreat it. Maximum erroneous responses were given by Group II. A weak positive correlation between diagnosis and treatment planning questions was found. Conclusion: The current knowledge on diagnosis and treatment planning among dentists' is still truncated, and hence, the overall perception of the general dentists toward periodontal treatment in India needs to be gauged so that the general dentists can call for introspection and betterment of their services.
Keywords: Dentists, India, knowledge, periodontal diseases, surveys and questionnaires
|How to cite this article:|
Sathyamurthy P, Padhye A, Gupta HS. Knowledge of diagnosis, treatment strategies, and opinions on periodontal treatment procedures among general dentists in an Indian urban population: A questionnaire survey. J Indian Assoc Public Health Dent 2018;16:62-71
|How to cite this URL:|
Sathyamurthy P, Padhye A, Gupta HS. Knowledge of diagnosis, treatment strategies, and opinions on periodontal treatment procedures among general dentists in an Indian urban population: A questionnaire survey. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2021 Jun 15];16:62-71. Available from: https://www.jiaphd.org/text.asp?2018/16/1/62/228293
| Introduction|| |
Epidemiological research indicates that periodontal diseases are a global pandemic and evidence shows a prevalence of 50%–100% in geographically diverse Indian subcontinent., The WHO reports that 15%–30% tooth loss is found in adults and that an early diagnosis with immediate implementation of treatment can accomplish prevention and management of periodontal diseases. Today, the specialty of periodontology has evolved shifting paradigms, thus enabling higher level of predictability of success in saving periodontally compromised teeth previously deemed with poor or questionable prognosis. Holistic interdisciplinary approach is the mainstay of current treatment strategies that achieve a higher level of predictability and aim at rehabilitating patients' life as a whole.
A predominant urban population with a higher occurrence of periodontal problems visits private dental clinics across India. The liability to first examine and evaluate the need for referral rests solely in the hands of the general dentist. A thorough knowledge in diagnosing and formulating a sound treatment plan is an essential skill that every clinician should master. A few clinical scenarios do exist that beckon for prudence on behalf of the general practitioner to call in for specialist intervention [Table 1] and [Table 2]. As there are no set rules, each dentist must be accountable with the decision to treat or refer. Well-timed specialist intervention may preserve a patient's confidence, oral health, and the overall quality of life while a delay could jeopardize a salvageable situation into a hopeless one. Currently, nonsurgical periodontal therapies could be combined with hard and soft-tissue grafting, perioplastic procedures, etc., that increase the chances of success along with receiving laudable patient cooperation.
|Table 2: Summary of questions receiving <40% correct response from the three groups|
Click here to view
A greater proportion of general dentists are unaware of the basic periodontal treatment needs as evidenced by the documented rise in advanced periodontal diseases culminating in tooth loss. Dental students have a limited educational background in periodontics, thereby conflicting the claim that they can supervise, let alone offer, the full scope of periodontal therapy., Limited data exist regarding the demographic predictors of referral for the specialty of periodontics. This establishes a need to evaluate the views and practices of general dentists along with their diagnostic acumen to correctly identify periodontal pathologies.
Furthermore, it is necessary to gauge their outlook with regards to the end points of periodontal therapy. This survey aims to outline the trending level of patient care offered by the general practitioners in urban India which would guide us in taking active measures to uplift the same, thereby skirmishing the status quo. Since there is a dearth of literature, we conducted a self-administered close-ended questionnaire survey to explore and evaluate the knowledge of diagnosis, treatment strategies, and opinions of general dentists on the periodontal treatment procedures.
| Methods|| |
A pilot survey was undertaken for 100 registered dentists with a Bachelor of Dental Surgery degree, currently practicing in Mumbai, India, for the past 2 years. This study was approved by the institutional ethical review committee (IERC no. 28/2015). General dentists not registered with Dental Council of India, in practice for <2 years and with a Master of Dental Surgery degree were excluded.
Piloting of questionnaire
Previous studies were used as a starting point for discussion that was adapted to the prevailing Indian conditions and an initial questionnaire with 24 questions was prepared. A focus group of 7 general dentists and an expert group of 5 periodontists was chosen to determine the questionnaire reliability at 0 and 3 weeks, to be answered within 15 min. If at least 60% of the experts agreed with a question, their opinion was accepted as the correct answer, and the responses of focus group were compared with the same. Item and factor analysis was done for every question to determine individual domains. Internal and external reliability (r = 90) was assessed and Cronbach's α correlation was found to be >75%.
A final self-administered close-ended questionnaire with 18 questions was handed to 100 general dentists fulfilling the inclusion criteria and consented to be a part of this study. The aim of the study was explained and anonymity was assured. The questions were divided under 3 domains: (1) Q. 2, 6, 8, 10, 13, and 13i assessed the diagnosing ability; (2) Q. 3, 4, 5, 7, 9, 11, 12, 13ii, and 13iii assessed the treatment planning skills; and (3) Q. 14, 15, 16, 17, and 18 assessed their perception of periodontal treatment outcomes. Questions 4i, 4ii, 6, 7, 13i, 13ii, 13iii, 14, 17, and 18 were assessed as percentage of response. For questions 3, 4, 8, 10 11, 12, 13, 15, and 16, the correct responses were scored as 1 and the incorrect responses were scored as 0. For questions 2, 5, and 9, they were asked to rank the options and a score of 1 was given for responders whose rankings matched with that of the expert group [Appendix 1 [Additional file 1]]. Final sample size was 92 as 8 questionnaires were only partially answered and hence were excluded from the analysis.
Data were tabulated in Microsoft Excel (MS office version 2010) and analyzed using Windows PC-based software “MedCalc Statistical Software” version 13.3.1 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2014) at alpha 0.05 (95% confidence limits). Pearson's correlation coefficient test was used to identify any significant associations between the responses. Chi-square test was used to compare the responses of general dental practitioners.
| Results|| |
The average experience of the general dentists was 8.41 ± 4.54 years (range: 2–35 years). Based on their experience, the survey population was divided under three groups; Group I (n = 17, 18.7%) with <5 years of experience, Group II (n = 42, 45.7%) with 5–<10 years of experience, and Group III (n = 33, 35.9%) with ≥10 years of practice. On an average, 64.7% of correct responses were noted. [Table 3] summarizes the details of the percentage of responders for all questions.
Necessity for performing complete scaling for all patients was agreed on by 95.7% of general dentists (Q. 3). A total of 85.9% felt that there were higher chances for recurrence of periodontal diseases and opted to retreat it (Q. 15 and 16). When the questions based on various domains were scrutinized, it was noted that general dentists could answer questions based on perception more appropriately. On an average, questions based on treatment planning received less correct responses. However, the comparisons between the groups were not statistically significant [Table 4]. It was observed that two questions (Q. 9 and 12) received <40% correct responses and a comparison was done to signify changes in trends across the three groups. It was seen that maximum incorrect responses were given by Group II with only 11.3% and 26.2% answering correctly for questions 9 and 12, respectively.
|Table 4: Summary of correct responses of the three groups to the various domains|
Click here to view
Using Pearson's correlation coefficient, a correlation matrix was generated. On analysis, a weak positive correlation of 0.079 was seen between Q. 3 and 5. A correlation of 0.051 was found between Q. 8 and 9. A strong positive correlation of 1.00 was found between Q.15 and 16. Statistically significant correlation was seen between Q. 10 and Q.12 (0.044), Q.9 and Q.17 (0.046), and between Q.15 and Q.16 (<0.0001) [Table 5].
|Table 5: Correlation between questions of diagnosis and treatment planning|
Click here to view
| Discussion|| |
This questionnaire survey was aimed at general dentists, segregated in three groups based on experience, who interact with a large number of varied patients on an everyday basis. The questionnaire was styled in a closed personal manner, and a realistic response analysis was carried out. It was noted that on an average, 64.8% of general dentists could give correct responses. However, this value is still truncated considering the fact that they form the first line investigators for dental and specifically periodontal problems across the city.
It was interesting to note that 95.7% of the general dentist performed full-mouth scaling for all patients, which complies with evidence-based treatment strategy fundamental in addressing periodontal diseases. A general tendency of responding correctly was seen in Group II followed by Group III. This ironically portrays that with an increase in clinical experience, a decline in positively diagnosing and treating periodontal disease was observed. Although the general dentist attends a 4-year program, he clocks in 240–260 h in the specialty of periodontics as compared to approximately 6000 h by the periodontal specialist. Furthermore, there is a lack of resources for continuous appraisal of knowledge and skill sets of graduated general dentists. These factors may lead to a decline in the overall quality of practice. Established dentists with increasing years of practice and experience usually refer patients to a specialist. On the contrary, fresh graduates are coerced to retain maximum patients in their own practices, providing debatable quality treatment, as they may be burdened with higher education loans than dentists of earlier cohorts. A similar tendency was noticed in this survey, wherein 69% were either referring patients to periodontists or had a consulting periodontist visit their practice. Out of this, 57.8% consulted a periodontist only once in 6 months and as low as 14% responders called them once a week. On group-wise segregation, 16%, 54%, and 30% of dentists from Groups I, II, and III, respectively, were consulting a periodontist. The responders who did not consult a specialist opined that very few patients got motivated for periodontal treatment owing to the fact that periodontal diseases being usually chronic remain symptomatic till a much later stage.
Loss of attachment was chosen by 71% of responders as the primary cause of mobility, out of which 73% opined to perform scaling and root planing and reevaluation for Grade I mobility while 64% agreed to consult a periodontist for Grade II and 67% opted for extraction of teeth exhibiting Grade III mobility. These responses seemed to be closely matching with that of the expert group. However, mobility of the teeth cannot be a true determining factor as a decrease in inflammatory infiltrate could establish stability of teeth., Two-thirds of the general dentists could diagnose the presence of a periodontal pocket and furcation involvement. However, only 16.3% and 21.7% dentists could choose the correct treatment plan. The correlation between diagnoses and treatment of periodontal pockets and furcation defects was found to be weak (0.05 and 0.2, respectively). This hints toward a lack of knowledge and awareness among the general dentists. At present, a large disparity exists for deciding between treatment or extraction of the periodontally compromised teeth. This decision-making algorithm is affected by numerous factors such as technical-scientific knowledge, experience, tradition, beliefs, and habits.
A total of 70% responders stated that they evaluated for mucogingival defects, of which 2/3rd identified gingival recessions and <1/4th examined for other defects such as aberrant frenum, inadequacy of attached gingiva, or interproximal papilla loss. Nearly 50% did not opt for referral to a periodontist for treatment of such defects. Thus, it can be fairly said that an incongruence in diagnosing mucogingival defects leads to nonreferral or delayed referral culminating in detriment of patients' existing periodontal health. This finding was similar to a study done by Grover et al. which stated that dentists often neglect the scope of perioplastic surgeries because of lack of awareness and professional competence.
It is a well-known fact that periodontists receive extensive clinical training and are familiar with the latest techniques for diagnosing and monitoring periodontal diseases and are trained in performing advanced periodontal procedures. A general dentist can perform procedures of various specialties such as endodontics and oral surgery, but to profess that their practice and skill is the same as those who specialize in the above-mentioned areas is unwarranted. A negative perception of these dentists with regard to success of periodontal therapy stems from the fact that their ineffective treatment planning results in inadequate resolution of periodontal diseases and their sequelae. Furthermore, they hold patients liable for this continual saga. However, they are professionally and ethically obligated to ensure that the best line of treatment is offered, irrespective of cost or time factor.
This was a pilot study with a sample size of 100 that may not be satisfactorily representative of the entire population. A further limitation of this study is that the specificity and sensitivity of the diagnosing ability of the dentists were not assessed, possibly overlooking the factual proficiency of the dentist in question. Although the questionnaire tried to incorporate the various aspects of periodontal diagnosis and treatment planning, additional questions based on attendance of continuing dental education (CDE) programs, various flap procedures, dental implants, and periodontal practice integral to interdisciplinary dentistry could have given us further lucidity on the subject.
| Conclusion|| |
From this pilot survey, it was noticed that the current knowledge on diagnosis and treatment planning among dentists' is still reduced. Furthermore, poor choice and patterns of referral lead to inadequate planning and execution of treatment. Hence, the overall perception of the general dentists toward periodontal treatment in India needs to be gauged so that the general dentists can call for introspection and betterment of their services.
Scope for general dentist
The general dentist should be persuaded about the important role he plays in motivating the patients and devising a customized treatment protocol including referral and recall. He should emphasize on building a professional partnership with the periodontist so as to harness their aptitude and competence for the treatment of periodontal diseases. Seminars, courses, and CDE programs should be attended so as to imbibe knowledge regarding the newer periodontal treatment procedures. The current knowledge and practice among dentists should be gauged by conducting regular assessment tests at national level. Furthermore, pro bono practice hours should be dedicated to render quality care for the needy.
Scope for patient
Patients should be made aware of timely periodontal treatment to enhance the longevity of their dentition as compared to its cost-benefit ratio. Various national schemes such as health insurance and early intervention centers should include periodontal procedures to support patients who cannot afford treatment otherwise. Mass media should be beneficially used for educating people on dental and specifically periodontal problems and their consequences.
We would like to thank Dr. Richard Pereira, Professor, Department of Periodontics, MGM Dental College and Hospital; Dr. Vineet Kini, Professor, Department of Periodontics, MGM Dental College and Hospital; Dr. Tushar Pathak, Senior Lecturer, Department of Periodontics, MGM Dental College and Hospital; Dr. Deepak Langade, Professor and Head of the Department, Department of Pharmacology, Bharati Vidyapeeth Dental College for helping with survey validation and data analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Savage A, Eaton KA, Moles DR, Needleman I. A systematic review of definitions of periodontitis and methods that have been used to identify this disease. J Clin Periodontol 2009;36:458-67.
Agarwal V, Khatri M, Singh G, Gupta G, Marya CM, Kumar V. Prevalence of periodontal diseases in India. J Oral Health Commun Dent 2010;4:7-16.
Pihlstrom BL. Periodontal risk assessment, diagnosis and treatment planning. Periodontol 2000 2001;25:37-58.
Mali A, Mali R, Mehta H. Perception of general dental practitioners toward periodontal treatment: A survey. J Indian Soc Periodontol 2008;12:4-7.
] [Full text]
Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000 2004;34:9-21.
Goel K, Goel P, Goel S. Negligence and Its Legal Implications for Dental Professionals: A Review. Advisory Board Prof. Rakesh Kumar Mudgal; 2014. p. 113.
Ali K, Tredwin C, Kay EJ, Slade A, Pooler J. Preparedness of dental graduates for foundation training: A qualitative study. Br Dent J 2014;217:145-9.
Shashikiran ND, Subba Reddy VV, Patil R. Periodontal referral. Malay Dent J 2007;1:28.
Wilson RD. Referrals to specialists. In: Wilson TG. Kornam KS, editors. Fundamentals of Periodontics. Chicago: Quintessence Publishing Co. Inc.; 1996. p. 457-9.
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.
Zemanovich MR, Bogacki RE, Abbott DM, Maynard JG Jr., Lanning SK. Demographic variables affecting patient referrals from general practice dentists to periodontists. J Periodontol 2006;77:341-9.
Straub-Morarend CL, Marshall TA, Holmes DC, Finkelstein MW. Toward defining dentists' evidence-based practice: Influence of decade of dental school graduation and scope of practice on implementation and perceived obstacles. J Dent Educ 2013;77:137-45.
Lee JH, Bennett DE, Richards PS, Inglehart MR. Periodontal referral patterns of general dentists: Lessons for dental education. J Dent Educ 2009;73:199-210.
Delatola C, Adonogianaki E, Ioannidou E. Non-surgical and supportive periodontal therapy: Predictors of compliance. J Clin Periodontol 2014;41:791-6.
Ioannou AL, Kotsakis GA, Hinrichs JE. Prognostic factors in periodontal therapy and their association with treatment outcomes. World J Clin Cases 2014;2:822-7.
Grembowski D, Milgrom P, Fiset L. Factors influencing dental decision making. J Public Health Dent 1988;48:159-67.
Grover V, Kapoor A, Malhotra R, Sachdeva S. Interest and satisfaction of dentists in practicing periodontics: A survey based on treatment of gingival recession. Dent Res J (Isfahan) 2012;9:404-13.
Kornman KS, Giannobile WV, Duff GW. Quo vadis: What is the future of periodontics? How will we get there? Periodontol 2000 2017;75:353-71.
Ozar DT, Sokol DJ. Dental ethics at chairside: professional principles and practical applications. 2nd
ed. Washington, DC: Georgetown University Press, 2002.
Baelum V, van Palenstein Helderman W, Hugoson A, Yee R, Fejerskov O. A global perspective on changes in the burden of caries and periodontitis: Implications for dentistry. J Oral Rehabil 2007;34:872-906.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]