PERIODONTAL PRACTICE AND REFERRAL OF PATIENTS BY GENERAL DENTAL PRACTITIONERS IN PROVINCE NO.1 NEPAL

ABSTRACT


INTRODUCTION
The prevalence of periodontal disease globally is reported to 1 range from 20-50%. In the context of Nepal, 52.5% and 47.5% of the popula on were found to suffer from 2 periodon s and gingivi s respec vely. These data though old indicate that there is an overwhelming number of pa ents who need mely interven on so as to maintain the func onal and esthe c integrity of the den on. Moreover, periodontal diseases do not show many symptoms unless they have reached advanced stages of destruc on. As a result, early diagnosis becomes crucial. The liability to examine and evaluate the need for referral rests solely in the hands of general dental prac oners 3 (GDPs). GDPs include dental graduates registered at professional council of the country who prac ce den stry as per the rule of law. They also include dental graduates with a specializa on in one of the branches of den stry, also registered in the council, who nonetheless prac ce general den stry besides offering their exper se care. As per evidence, only a small frac on of GDP's me is dedicated to the preven on, diagnosis, and management of periodontal 4 diseases. However, Lanning et al. stated that a variety of periodontal services were offered by GDPs in the state of Virginia. The most common services provided were nonsurgical in nature and regarding surgical interven ons, referrals were made for procedures like surgical pocket management, so ssue gra s, guided bone/ ssue 5 regenera on, implant placement, etc. Similar findings were 6,7 reported by studies done in a few parts of India. Unfortunately, there is a remarkable dearth in dental literature regarding informa on about various types of periodontal prac ces and referrals rendered by GDPs to [5][6][7][8] periodon sts globally including Nepal. Therefore, as a new start, the present study was designed to collect informa on about the varie es of periodontal therapies performed and referred by GDPs in province one. Such informa on is an cipated to establish and maintain a sound referral base which is vital to a successful specialty prac ce. found that 98% of the GDPs performed a phase I therapy.

METHODOLOGY
Using one propor on formula for sample size es ma on: n= 2 2 z p(1-p)/d where, z= 1.96, p= 98 and absolute precision (d) of 3% and adding 10% to reduce various biases sample size was calculated to be 93. The total popula on of general dental prac oners in province one is (n) 125. Considering finite popula on correc on factor, sample size was adjusted to 54. Taking into account the low response rate from the esurvey, the adjusted sample size was inflated to include all popula on. Hence, all the general dental prac oners prac cing in private dental clinics in province one who agreed to give consent were included in the study. Periodon sts, dental students, interns, and den sts working exclusively in academic ins tutes were excluded from the study. A self-administered ques onnaire developed by Mali et al., modified according to our prac ce setup was used in the 6 study. The ques onnaire was prepared using Google forms via docs. google.com/forms and the link was emailed to the enrolled par cipants including a brief introduc on on the background, the objec ve of the study, voluntary nature of par cipa on, declara ons of confiden ality and anonymity followed by ques ons on demographic and professional details, periodontal prac ce and referrals of pa ents. Only those par cipants who agreed to consent were allowed to respond in the subsequent sec ons. The filled ques onnaires were extracted from Google Forms and exported to Microso Excel 2007 and converted into Sta s cal Package for Social Sciences version 20 for sta s cal analysis. Descrip ve sta s cs were calculated like percentage, frequency, mean, and standard devia on (SD).

RESULTS
Of 125

DISCUSSION
Tradi onally, an interdisciplinary model of therapy with general den sts and specialists together for periodontal treatment has been considered to have an effec ve 9 outcome. Newly graduated general den sts are considered 10 to be the best source of referral for periodon sts.
Regarding periodon sts they are familiar with the latest techniques for diagnosing and monitoring periodontal diseases as well as trained extensively in performing 11 advanced periodontal procedures. A sound referral-based system can contribute to the mely diagnosis and treatment of periodontal diseases hence reducing the incidence of periodontally challenging cases in the community.
In the present study, the response rate was found to be [64(51.2%)] which is rela vely higher than the recently reported average response rate for online surveys in a metaanalysis. The meta-analysis considers a 44% response rate to 12 be reasonable for online surveys in educa on-related field. The study precluded dental prac oners working in academic ins tutes because both the den sts and specialists working in academic ins tutes follow the referral protocol as per the pa ent's need. Moreover, the den sts must work under specialized supervision. So, the target popula on was GDPs working in private clinics whose periodontal prac ce and referral had to be surveyed. The majority of the surveyed GDPs rou nely performed fullmouth periodontal examina ons in all pa ents as well as comprehensive periodontal examina ons in pa ents with periodon s. This implies, despite the diversity in their dura on of prac ce ranging from one to 50 years and the cumbersome nature of comprehensive periodontal assessment, they seem to consider it as an integral part of the dental examina on and incorporate it into their private prac ce.
In the present study, majority of the GDPs performed nonsurgical periodontal therapy which is in accordance with the 5,[13][14][15] results of earlier studies. Basically, the procedures like scaling, instruc ons on oral hygiene maintenance, and use of mouthwash were mostly prac ced similar to the 16 Tasmanian registered GDPs surveyed in 2016. On the contrary, Lanning et al., and Ghiabi and Ma hews et al. reported scaling with root planing and periodontal maintenance as the most frequently prac ced periodontal 5,13 service. However, procedures like root planing, splin ng and management of food impac on areas were barely addressed by the GDPs in the present study. Indifference toward splin ng can be explained by the response of most GDPs who believed that reduced tooth mobility was an occasional outcome of periodontal therapy. Either such a tude, or lack of adequate knowledge regarding the management of mobile teeth must have demo vated them in handling pa ents with tooth mobility. Moreover, the irony is we are unaware whether these complaints are being addressed via referral to periodon sts or simply being ignored which is in contrast with the survey, where almost half of the GDPs were found to refer pa ents with chief 6 complaint of mobile teeth to the periodon sts. Regarding preference for referral in context to periodontal surgeries, majority referred the pa ents to periodon sts 5,6,13 like the findings of previous studies. Ghiabi and Mathews et al., and Linden in their survey reported the availability of periodon sts in the community as an important factor in 13,17 selec ng a periodon st. Also, a systema c review done to iden fy the non-clinical factors associated with periodontal referrals validated that loca on of specialists plays a pivotal role in deciding whether to make periodontal 18 referrals. Similarly, in this study the reason for such a bulk of referrals could be the availability of periodon sts either working in private clinics or academic ins tutes in the vicinity of province number one. Only 7.2% rendered periodontal surgeries, which is rela vely consistent with the studies conducted by Ghiabi  reported a higher percentage than the present study. Such varia ons could be a ributed to the na onwide differences in sample selec on, training received in undergraduate programs, further training or specific courses, and involvement of dental hygienists in their private prac ce. In this study, no such ques ons were asked which would reveal the presence or absence of dental hygienists in their prac ce. Interes ngly, most of the referrals were based on the presence of gingival recession and other mucogingival problems, presence of periodontal pockets, gingival enlargement, and implant placement. This finding is addi onally supported by their responses which reveal that procedures like flap surgery, GBR, and implant placement were managed by periodon sts. The data also hints that the referral by GDPs was focused on the cases they thought specialists should manage. This in a way also clarifies that the GDPs s ll respect and follow the "when to 20 treat and when to refer" protocol. However, those who did not refer cited different reasons for not referring out of which lack of pa ents who were mo vated for surgery was the most common reason. Similar reasons have been 5,11 reported by several studies done previously. This calls for periodontal health awareness campaigns rou nely targe ng varying groups of popula on.
There is consensus among the GDPs that there is a stoppage of bleeding from gums always a er periodontal treatment which can be a ributed to the fact that majority of their prac ce is limited to non-surgical therapy and scaling precisely for which almost all of them recall the pa ents for maintenance. This gives them an opportunity to evaluate and visualize the posi ve outcome. This finding again is in 6 line with a study done in Pune. However, they seemed to be skep cal about the posi ve outcomes of periodontal therapies like management of mobile teeth and, pocket elimina on and root coverage which lay the founda on of periodontal surgical procedures. This shows the lack of awareness among the GDPs regarding evolu on and recent advances in the field of periodon cs. In addi on to this, lack of awareness and maintenance among the pa ents was considered accountable for such recurrences. Regarding the cost-effec veness of periodontal procedures, most of the GDPs assumed it to be lucra ve which is in contrast with the study carried out among one hundred general dental 6 prac oners in India. Majority of the GDPs did not provide implant service to the pa ent and when asked about their choice of referral for the same only half of them opted for periodon sts. This is rela vely higher when compared to the GDPs prac cing in Pune where the majority did not believe that implants are an integral part of periodon st's armourand the study done in Belgaum, India where only 8% of the GDPs preferred 6,7 periodon sts for implant placement. Last but not least, there appears a contradictory response which reveals minimum par cipa on of the GDPs despite noteworthy sa sfac on regarding the number of CDE courses being conducted. This might be because loca on wise such programs are conducted beyond their reach. Hence, it seems crucial that we ensure maximum par cipa on of GDPs in such formal training or courses.

CONCLUSION
The result shows quite a good congruence with previous studies as majority of the GDPs seemed to perform nonsurgical periodontal therapy by themselves while considering referral for surgical interven ons. Only small number of par cipants preferred referring pa ents to periodon st for phase I therapy while referral for surgical interven on was recorded to be significant. Their par cipa on in CDE courses appears disappoin ng which could be responsible for their lack of awareness regarding the recent evidence-based updates and the posi ve outcomes of periodontal therapy.

RECOMMENDATIONS
The present study being the first of its kind to publish the informa on regarding periodontal prac ce and referral among limited Nepalese GDPs recommends a more elaborate mul center record-based study in future. The possible loopholes for insufficient par cipa on of the GDPs in formal educa on courses should also be iden fied. Easily accessible con nuing dental educa on (CDE), focusing more on preven ve and surgical aspects of periodontal problems as well as periodontal health awareness programs targe ng varying groups of popula on should be rou nely conducted.

LIMITATIONS OF THE STUDY
There are limita ons to this study which includes par cipa on of GDPs from selec ve districts of province no. 1, the result of which cannot be generalized to the en re GDPs prac cing in the province. Also, the results of the current study are based on GDP's self-reported prac ce and referral behaviors. A certain degree of response bias can be expected in the study. Despite the limita ons, the study contributes to the exis ng literature on periodontal prac ce and referral among GDPs which is limited globally and provide mo va on to conduct studies further to assess en re GDPs prac cing in Nepal.