|Year : 2015 | Volume
| Issue : 1 | Page : 7-11
Rationale of referral of patients to a periodontist by general practitioners: Review with a cross-sectional survey
Deepthi Anna Cherian1, MM Dayakar1, Tim Peter Thermadam2
1 Department of Periodontics, K.V.G Dental College and Hospital, Sullia, Dakshina Kannada, Karnataka, India
2 Department of Oral Medicine and radiology, K.M.C.T Dental College, Calicut, Kerala, India
|Date of Web Publication||12-Aug-2015|
Deepthi Anna Cherian
Department of Periodontics, K.V.G Dental College and Hospital, Sullia, Dakshina Kannada, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Periodontology is a fast evolving field where newer insights into existing concepts are changing the face of the traditional periodontal treatment. However, the protocol of periodontal referrals has undergone little change over the last decade. This emphasizes the need for more research into what has been happening in the field of dental practice with a view of achieving the best prognosis for the patient's ailment. A questionnaire study was carried out in the form of a survey among 102 general dental practitioners to assess the knowledge update and periodontal referral relationship among general practitioners (GPs). Aim: The aim was to assess the knowledge update regarding advanced periodontal procedures among general dental practitioners. Materials and Methods: A survey form was distributed to 102 general dental practitioners having their dental clinics in and around Mangalore city with, qualification of Bachelor of Dental Surgery only. Results: The following trends were noted: (1) 71% of private practitioners referred patients to periodontists for surgical therapy. (2) About 50% GPs refer patients to periodontists for ridge augmentation and implant procedures. (3) 76% of GPs have attended <5 continuing dental education (CDE) programs in the past 1-year. (4) 92% of the GPs performed phase-1 therapy on their own. Conclusion: Majority of the private practitioners perform phase-1 therapy on their own, but the referral relationships have improved. Although almost half the number of private practitioners is aware of the procedures like implants and ridge augmentation, it is important to keep the knowledge updated by attending more CDE programs.
Clinical relevance to interdisciplinary dentistry
The referral of patients to specialist needs to improve and all dentist must be updated of the current trends in dental practice
Keywords: American Association of Periodontology, continuing dental education, general dental practitioners
|How to cite this article:|
Cherian DA, Dayakar M M, Thermadam TP. Rationale of referral of patients to a periodontist by general practitioners: Review with a cross-sectional survey. J Interdiscip Dentistry 2015;5:7-11
|How to cite this URL:|
Cherian DA, Dayakar M M, Thermadam TP. Rationale of referral of patients to a periodontist by general practitioners: Review with a cross-sectional survey. J Interdiscip Dentistry [serial online] 2015 [cited 2020 Sep 23];5:7-11. Available from: http://www.jidonline.com/text.asp?2015/5/1/7/162737
| Introduction|| |
Dental surgeons in India in the past decade or so had developed a habit of carrying out the specialized treatment procedures by themselves abstaining from the referral of the patient to the consultant specialist in the field. It has its pros and cons which have be enlightened upon. This emphasizes the need for more research into what has been happening in the field of dental practice with a view of achieving the best prognosis for the patient's ailment.
A typical scenario in the dental clinics around us is that only the patient's symptoms are addressed to. Sadly, periodontal disease do not show much symptoms unless it has reached advanced stages of destruction.  Early diagnosis is thus of utmost importance. Early recognition of periodontal disease by general practitioners (GPs) was practically nil and condition has not improved much. It was not until the devastation of the disease became obvious that the patients were and are referred to periodontists. Hence, it becomes very important for all and especially the general dentists to examine, evaluate, and diagnose the periodontal problems the patient has and guide the patients properly. Thus, a basic periodontal examination of all teeth should be mandatory.
Referral trend that is seen in Indian scenario shows that established dentist usually refer patients to a specialist. Many studies have pointed out that younger graduates have to repay, on average, higher education loans at the time of their graduation from dental school than dentists in earlier cohorts. They speculated that this higher rate of debt could lead younger dentists to try to keep more patients in their own practices for periodontal treatment and for the maintenance portion of their periodontal treatment as opposed to having periodontists and their staffs provide this treatment.  This common trend seen in general dentist to keep patients in their practice for years performing repetitive sessions of soft tissue management treatment, with no referral offered results in worsening of their periodontal condition and most of the time patients are on the verge of losing their teeth. Such patients, when referred, are not benefited from the services of a specialist. Thus, the services of a periodontist are underestimated both by the patient and the general dentist.
In this new and unfortunate scenario, it can be opinioned that the patient will appreciate the knowledge of the practitioner to diagnose the condition and will only be more pleased to be under specialist care. The work efficiency of a periodontist will also be better than GPs as they can dedicate more time to a single case and would actually know what he or she is doing.  With better and effective treatment rendered the patient will be more confident to come to the same practitioner for any dental problems. This problem arises especially when the general dentist sends a patient to the specialist and does not see the patient again or get any input back from the specialist or specialist tells the patient what needs to be done without first informing the general dentist. Each specialist should have a professional responsibility to refer the patient back to the dentist so that a give and take relationship is established.
To the best of our knowledge, no study has been conducted to assess the knowledge update and referral relationship among GPs. This study, by the means of a questionnaire, aims to identify the referral relationship between GPs and periodontists and awareness of advanced periodontal therapy among GPs in Mangalore City.
| Materials and methods|| |
The study was carried out in the form of a survey among 102 general dental practitioners having their dental clinics in and around Mangalore city. A questionnaire [Appendix I [Additional file 1] ] comprising of seven questions with sub-questions were prepared.
Dental practitioners with a dental clinic in an urban area, nonacademicians, qualification of Bachelor of Dental Surgery only, and experience of at least 1-year in private clinical setup were included for the study.
Interns, dental students, dentists exclusively working in a dental institute and dentists with the qualification of Master of Dental Surgery were excluded from the study.
The questionnaire was distributed to each of them by visiting their clinic.
For each question, independent percentage was calculated to determine the frequency of the responses. To identify the variable factor affecting the responses, multivariate logistic regression analysis test was used.
| Results|| |
Of 102 dentists included, the average years of experience were 5.2 years ranging from 1.6 to 24 years. The results revealed that 92% of the GPs performed phase-1 therapy on their own. Our survey indicates that the role of a periodontist in private dental clinics in Mangalore is chieﬂy limited to surgical therapy. It was observed that 71% of private practitioners referred patients to periodontists of which majority had clinic since more than 10 years [Figure 1].
Almost half of the GPs referred patients to periodontists for procedures like flap surgery, ridge augmentation and implants. Another interesting response to be noted is that majority of dentists (69%) referred patients to a periodontist for the chief complaint of mobile teeth.
Half of the dentists recalled patients after 3 months of surgical treatment. Though the recall was made after 3 months many dentists commented that patient's compliance was a problem. About 76% of GPs have attended < 5 continuing dental education (CDE) programs in the past 1-year [Figure 2]. The results of the study showed that 66.3% of general practitioners refered flap surgery cases to specialist. 39.6% of practitioners did not practise depigmentation procedures in their clinic.About 50% practitioners refered ridge augmentation and implant cases to specialist.
|Figure 2: Results of the study (a) unaware of the procedure (b) aware of the procedure but do not practice it. (c) Practice the procedure in your clinic by yourself (d) done by a periodontist visiting the clinic|
Click here to view
| Discussion|| |
Interdisciplinary treatment in dentistry creates a triad made up of the referral doctor, referral patient, and the specialist. The value of this coordinated diagnosis and treatment approach is for everyone in the triangle to win. The success of this triad depends on teamwork, mutual understanding and respect among the team members. Mutual acceptance by the general dentist and specialist as professional peers, subject to each other's critical professional evaluation with a teamwork is essential for any interdisplinary referral.
Scope for general dentist
It is a common complaint among periodontists that the knowledge and mindset of a general practitioner who is not attached to a teaching institute are limited to the level that was attained during their graduation.  Dental students receive only a limited educational background in periodontics that does not support the claim that GPs can supervise, let alone offer, the full scope of periodontal therapy in cases demonstrating high period risk factors, as evidenced by the documented rise in advanced periodontal diseases and loss of teeth. 
Over a 10-fold increase in unnecessary tooth loss in practices that rely on soft tissue management protocols as the sole form of periodontal care was reported in a formal study published in the Journal of Periodontology.  Our study showed that majority GPs referred their patients to a periodontist when teeth showed signs of mobility. In a study of a similar pattern Mali et al. also concluded that almost half the number of dentists referred patients to a periodontist for the chief complaint of mobile teeth In such cases periodontal intervention would only give unpredictable results. The American Association of Periodontology guidelines was written to help dentists identify if and when a patient should be referred to a periodontist, which if followed would help to overcome the hinges in the referral patterns.
The general dentist should be emphasized the importance of regular gingival examination and referral to a periodontist for periodontal problems. He should also be convinced about the important role that a periodontist plays in multidisciplinary dentistry. The results of our study proved that majority GPs attend <5 CDE programs/year. More number of CDE programs should be conducted and attended so as to impart knowledge regarding advanced periodontal procedures and armamentariums. Also, various journals are freely accessible, which help to understand in detail, especially the advances in surgical procedure and the newer concepts.
Scope for periodontist
The referral procedure in periodontal treatments involves the mutual care and treatment of the same patient shared between the referring doctor and the periodontists to whom the patient has been referred. The results of our study showed that 71% of dentists referred patients to a specialist. Many factors like clinical, personal and cost influence the decision to refer a patient to a specialist. This makes the referral process a complex entity in the everyday practice of dentistry. 
To improve the referral relationship the patient, the referrer and the specialist have the responsibility to communicate well and be informed and educated to each other's needs. The three most common criteria reported for selecting a periodontist were previous patient satisfaction, the personality of the periodontist and previous success with the periodontist. Other common criteria were good communication with the periodontist, surgical skills and competency of the periodontist and availability in the community. 
Patient factors such as smoking and the patient's willingness to cooperate with oral hygiene instructions also need to be considered when planning treatment for a patient with the periodontal disease.  Thus patient motivation and corporation are an integral part of any dental treatment.
The specialty of periodontology is evolving in all aspects ranging from newer advances in diagnosis to the use of growth factors and regenerative techniques in treatment. These evidence-based advances have given periodontal diagnosis and treatment a higher level of predictability of success. It is a known fact that the perceptions and beliefs about the responsibilities of the dental professional, as well as knowledge about resources and available support services, forms the cornerstone of any dental practice. Studies should be performed in future to get an overall perception of the general dentists toward periodontal treatment in India. Such studies performed at different intervals of time in the same cities can also provide an idea about the changing trends and pattern of dental treatment performed by the general dental practitioners.
| Conclusion|| |
Teamwork and leadership are essential in the successful interdisciplinary referral. The general dentist, however, is the professional who knows the patient best and must take the lead in developing the treatment plan and its sequence and coordination. He should utilize the clinical skills of the specialist (s) and his area of expertise, and then manage the continuing care of the patient.
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[Figure 1], [Figure 2]