Periodontal Referral Patterns, 1980 Versus 2000: A Preliminary Study

Dental Students’ Knowledge, Confidence, Ability, and Self-Reported Difficulties in Periodontal Education: A Mixed Method Pilot Study

Evidence on periodontal education areas in which students have difficulties and their factors are limited. In this study, third- and fourth-year dental students’ knowledge was assessed as well as their confidence and ability in five periodontal educational areas using a mixed-method approach. A survey was used to collect data related to history-taking, medical examination, diagnosis, treatment planning, and follow-up. Student answers were compared to the consensual answers of an expert panel using the cosine-similarity index (CSI). Descriptive statistics assessed confidence and ability for diagnosis. Semi-structured individual interviews were used to collect data on reported reasons for difficulties in periodontal education. A content analysis was employed to analyze the interview data. Eighteen third- and fourth-year dental students completed the survey and eleven were interviewed. Students’ knowledge was adequate regarding diagnosis and treatment planning. Third-year students’ median CSI were 0.93 and 0.89, respectively. Fourth-year students’ median CSI were 0.9 and 0.93, respectively. Students felt confident in history-taking and examination but lacked confidence and ability in diagnosis and treatment planning. Reported reasons for difficulties in periodontal education were linked to both preclinical and clinical pedagogical issues. Further improvements in preclinical and clinical periodontal education are needed to address students’ lack of knowledge, confidence, and skills in key periodontal areas.

Periodontal referral patterns in Norway: 2003 versus 2018

Objectives

Changes in periodontal referral patterns over time have been reported from the United States and Australia. To date, comparable studies have not been published from Europe. The objectives of the present study were to examine changes in periodontal referral patterns in Norway in 2003 versus 2018 and to compare these with trends observed in the United States and Australia using universal criteria for grading of periodontal severity.

Materials and methods

A retrospective analysis of 369 charts from four Norwegian periodontics clinics was completed. Data on year of referral, gender, age, tobacco smoking, periodontal status and missing teeth at initial examination, teeth planned for extraction, and periodontal case type were collected using a survey format; case type I, II, III, and IV representing increasing severity of periodontitis, case type V representing referral for other periodontal conditions (peri‐implantitis, refractory periodontitis, etc.). Chi‐square, t‐tests, and negative binomial regression were used for the statistical analysis.

Results

Compared with 2003, the 2018 data showed an increase in mean age at referral (p < 0.05), overall distribution of case type III and V (p = 0.047), and number of missing teeth (p = 0.001). Further, a decrease in prevalence of smokers (p < 0.05), but no change in number of teeth planned for extraction (p = 0.104), were observed.

Conclusions

During a period of 15 years, changes in periodontal referral patterns in Norway are similar to those in the United States and Australia. The adoption of a guideline‐based referral practice might be beneficial for both the dental profession and patients.

Factors affecting periodontal disease referral and the adherence to guidelines among general dentists

BACKGROUND

Current research highlights a need to investigate the factors affecting periodontal disease referral. Limited literature exists on periodontal disease referral in Australia and no comparison to the periodontal disease referral guidelines exists.

OBJECTIVE

This study analyses the factors affecting periodontal disease referral and the adherence to guidelines in general dentists in Queensland, Australia.

METHODS

Fifty-seven general dentists who are members of the Australian Dental Association (Queensland) undertook an online survey.

RESULTS

The disease factor regarded as most important (90% of respondents) was unresolved inflammation upon re-evaluation. The non-disease factor regarded as most important (79% of respondents) was the operator's level of training. There is low awareness of the guidelines (36.7%) yet a reasonable adherence to them (78.3%). Of those aware of the guidelines, there was a statistically significant poorer adherence to the guidelines compared to those unaware (P = 0.036), while there is no significant difference in the adherence to guidelines between those who have and those who have not attended continuing professional development (CPD) courses (P = 0.66).

CONCLUSIONS

Adherence to current guidelines is not significantly impacted by the level of awareness of the guidelines or CPD attendance. The results from this study suggest a need to refine the current guidelines to better inform decisions about periodontal disease referrals.

Scaling and root planing vs. conservative surgery in the treatment of chronic periodontitis

A renewed interest in conservative surgical techniques has been fueled by new technology, changes in referral patterns to periodontists and a desire to achieve periodontal health in the least invasive, most cost-efficient manner possible. Trends suggest that an increasing amount of periodontal care is being provided in the offices of general dentists. If true, it is likely that patients receiving care in these offices will be offered simpler surgical treatment modalities that do not require an extensive armamentarium. The purpose of this article was to review the effectiveness of six relatively simple surgical techniques - gingivectomy, flap debridement, modified Widman flap, excisional new attachment procedure, modified excisional new attachment procedure and laser-assisted new attachment procedure - and to compare the results obtained using these procedures with the well-known clinical benefits of scaling and root planing. The intent was to determine whether the benefits of surgical procedures in the hands of most general dentists extend beyond those of conventional nonsurgical therapy.

Periodontal diagnosis in private dental practice: a case-based survey

BACKGROUND

Despite the prevalence of periodontitis in Australia, there are few reports regarding periodontal diagnosis and therapies in the general dental practice setting. This study aimed to assess the degree of diagnostic accuracy in periodontal cases of Victorian general dental practitioners.

METHODS

Following ethics approval, dentists were invited to complete a scenario-based questionnaire on the Australian Dental Association Victorian Branch (ADAVB) website. Five text-based clinical scenarios (from a total of 10) were randomly presented, representing patients with a range of disease levels from periodontal health/gingivitis to severe periodontitis, and respondents were asked what examinations they would usually perform. Based upon the presented results of periodontal and radiographic examinations, a periodontal diagnosis was requested.

RESULTS

One hundred and thirty-five dentists attempted the survey. Most were in group practice and based in Melbourne; 22.5% of respondents worked in a practice employing a hygienist. The clinical parameters most commonly measured to diagnose periodontal disease were pocket depth and mobility. The majority of respondents diagnosed health, gingivitis and mild periodontitis correctly compared to American Academy of Periodontology guidelines. However, moderate periodontitis tended to be diagnosed as severe.

CONCLUSIONS

Dentists in Victoria used appropriate clinical parameters when assessing periodontal disease and were generally accurate in their diagnoses. There is a need for consensus regarding diagnostic definitions.

Economics of periodontal care: market trends, competitive forces and incentives

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.

Periodontal diagnosis affected by variation in terminology

BACKGROUND

The randomized case presentation (RCP) study is designed to assess the degree of diagnostic accuracy for described periodontal cases. This is to lay the basis for practitioner calibration in the Practitioners Engaged in Applied Research and Learning (PEARL) Network for future clinical studies.

METHODS

The RCP consisted of 10 case scenarios ranging from periodontal health to gingivitis and mild, moderate, and severe periodontitis. Respondents were asked to diagnose the described cases. Survey diagnoses were compared to two existing classifications of periodontal disease status. The RCP was administered via a proprietary electronic data capture system maintained by the PEARL Data Coordinating Center. Standard analytic techniques, including frequency counts and cross-tabulations, were used for categorical data with mean and standard deviation and median values reported for continuous data elements.

RESULTS

Demonstrable variations in periodontal assessment for health, gingivitis, and mild, moderate, and severe periodontitis were found among the 130 PEARL general practitioners who participated in the RCP survey. The highest agreement for diagnosis among dentists was for severe periodontitis (88%) and the lowest for gingivitis (55%). The highest percentage of variation was found in cases with health and gingivitis.

CONCLUSIONS

There was variation among PEARL practitioners in periodontal diagnosis that may affect treatment outcomes. Our findings add clinical support to recent publications suggesting a need for standardization of terminology in periodontitis diagnosis.

Factors influencing the periodontal referral process

BACKGROUND

General dental practitioners (GPs) assess the periodontal status of patients and make decisions to treat patients or refer them to a periodontist. There is little information available regarding this process. The purpose of this study is to identify significant factors that GPs consider important in selecting a particular periodontist. The findings were compared and contrasted with responses of periodontists to gain perspectives from both groups involved in the referral process.

METHODS

Data from an online cross-sectional survey of GPs (n = 533) and periodontists (n = 533) who practice in the southeastern region of the United States (from the databases of the American Dental Association and American Academy of Periodontology member directories) were obtained.

RESULTS

The specialist's clinical skill was identified as the most important factor influencing periodontal referrals by GPs, whereas periodontists identified a previous positive experience between a GP and periodontist as the most important factor. In a descending order of importance, the top three rating averages (rated out of five) by GPs were clinical skill (4.84), a previous positive experience between a GP and periodontist (4.57), and communication (4.52). The top three factors of periodontists were a previous positive experience between a GP and periodontist (4.66), communication (4.40), and the likelihood of a good patient and periodontist rapport (4.29).

CONCLUSIONS

The periodontist's clinical skill was chosen by GPs as the primary factor influencing the referral decisions of GPs. Periodontists perceived a previous positive experience between the GP and periodontist as the most influential factor. Further studies are required to gain more insight into the referral process.

Tooth loss in 776 treated periodontal patients

BACKGROUND

The most common form of periodontitis is a variably progressive dynamic pathologic process that causes attachment loss, destroys the alveolar bone supporting a tooth, and terminates with tooth loss. We evaluated the loss of teeth of treated periodontal patients categorized by severity and risk.

METHODS

Each of nine periodontists evaluated 100 consecutive periodontal maintenance patients. The disease severity and risk level were determined from data at the initial examination. The number of teeth lost was determined from data at the initial and maintenance visits.

RESULTS

A stepwise regression analysis showed that disease (P = 0.0000478) and risk (P = 0.00129) scores predicted the mean tooth loss rate. The adjusted R(2) statistic was 88.56%. The ordinal logistic regression model showed that only the disease score (P <0.0005) was significantly associated with the probability of patients losing a specific number of teeth.

CONCLUSIONS

Categorizing a patient by severity may be beneficial in the management of the periodontal patient. The disease score can be used to establish a criterion and target for care. For example, treatment can result in nearly no lost teeth when the severity is low, and this benefit is lost when the severity is high. The disease score provides an objective means to quickly determine severity. An increase in the disease score provides evidence that a new treatment plan is needed. Therefore, the effect of the routine use of the disease score could result in fewer patients with severe disease and reduce the number of teeth lost.

Objective, subjective, and self-assessment of preadolescent orthodontic treatment need--a function of age, gender, and ethnic/racial background?

Children from socioeconomically disadvantaged and/or underrepresented minority backgrounds in the United States have limited or no access to orthodontic treatment.

OBJECTIVES

To determine whether preadolescents' (a) objectively assessed orthodontic treatment need; (b) subjectively assessed orthodontic treatment need; and (c) self-perceptions of the psychologic aspects of their oral health-related quality of life and desire to have braces vary as a function of age, gender, ethnicity/race, and socioeconomic status (SES).

METHODS

Data were collected from 1,566 preadolescents (age range: 8 to 11 years; 47.3 percent male/52.7 percent female; 55.7 percent African-American/39.7 percent White/2.9 percent Hispanic) in oral exams and in face to face interviews. Malocclusion was determined with the Index of Orthodontic Treatment Need.

RESULTS

Children (17.2 percent) had definite treatment need, 33.7 percent were borderline, and 49.1 percent had little or no need. Objectively and subjectively assessed treatment need was not affected by the children's age or gender. However, girls were more critical of their smiles and wanted braces more than boys. The older the children were, the more critical they were and the more they wanted braces. African-American children and children in schools with higher percentages of children on free school lunches had less treatment need than White children and children in schools with lower percentages of students with free school lunches. While the provider-assessed treatment need was higher for White children than for Black children, Black children were less happy with their smiles than White children, and wanted braces more than White children. SES did not affect the children's self-perceptions.

CONCLUSIONS

Findings showed that substantial percentages of the preadolescents have an orthodontic treatment need. Orthodontic need and child self-perceptions varied as a function of the children's age, gender, ethnicity/race, and SES.

Periodontitis severity plus risk as a tooth loss predictor

BACKGROUND

Tooth loss can be a consequence of the natural history of periodontitis. Stratification of periodontitis severity, risk, and tooth loss exists within the United States adult population, and tooth loss correlates to severity and risk. We evaluated the loss of teeth for a periodontitis-affected population categorized by the combination of severity and risk in which the subjects predominantly did not receive periodontal treatment.

METHODS

The clinical records of 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study, covering a period of 15 years, were used. Disease severity, risk level, and the number of teeth lost for each subject were determined.

RESULTS

A stepwise regression analysis showed that disease and risk scores predicted mean tooth loss rate. The P value for the disease score was <0.0005, and the P value for the risk score was 0.001. The ordinal logistic regression model showed that disease (P = 0.002) and risk scores (P = 0.000) were significantly associated with the probability of subjects losing a specific number of teeth.

CONCLUSIONS

Tooth loss is more precisely and accurately predicted by the combination of risk score and periodontal disease score than by either score alone. The combined scores may be a surrogate variable for periodontal status. Because the scores are derived from routine clinical measurements, they may be useful for population surveillance and dynamics, practice management, patient care decisions, practice-based research, and the determination of treatment effectiveness and the factors required for successful treatment, resulting in improved oral health and higher clinician productivity and income.

Periodontal Services Rendered by General Practitioners

BACKGROUND

There are few reports in the dental literature regarding the types of periodontal services offered by general practitioners (GPs). The purpose of this study was to determine the specific nature of periodontal services rendered by GPs and to investigate whether certain variables affect GPs' practice patterns.

METHODS

A 13-item survey was mailed to a random sample of 600 dentists practicing in the state of Virginia. GPs were asked to identify the periodontal services rendered in their office within a 3-month period. Descriptive statistics, simple correlation, and stepwise multiple regression analysis were used to identify significant relationships between variables and periodontal services.

RESULTS

Ninety percent of GPs reported treating at least one patient with scaling and root planing, and 16% of GPs reported rendering this service to >36 patients. Eighty-six percent of GPs reported providing periodontal maintenance in their practices. Approximately 50% of dentists reported up to 24 patients having received periodontal maintenance. Fifty-eight percent of GPs reported that >or=90% of scaling and root planing was done by the hygienists. Fifty-five percent of GPs treated at least one patient with site-specific therapy using chemotherapeutic agents. Twenty-eight percent of GPs treated one to five patients with low-dose antibiotic. Seventy percent of GPs treated at least one patient with occlusal therapies, and 50% reported treating one to five patients with occlusal therapies. The most common surgical services performed included crown lengthening and pocket reduction surgery, which were done by 38% and 21% of GPs, respectively. A few GPs (N = 26) performed the majority of periodontal surgical services. Variables found to influence specific services rendered by GPs included year of dental school graduation, recent hours of continuing education related to periodontics, combined number of dental hygienist days per week, percentage of periodontal patients in practice, and referral for non-surgical periodontal therapy.

CONCLUSIONS

A variety of periodontal services were offered by GPs. The most common services were non-surgical in nature. Certain variables affected specific periodontal services rendered in general dental offices.

Relationship Between Prereferral Periodontal Care and Periodontal Status at Time of Referral

BACKGROUND

According to a recent study, the severity of periodontal disease of individuals referred for periodontal care is greater now than in 1980. Variability in the standard of periodontal care in general dental practices may result in less than desirable outcomes and consequences of poorer periodontal health.

METHODS

A sample of 100 newly referred dental patients from three separate periodontal practices in the greater Kansas City, Missouri area participated in this study. Data were collected from three sources: 1) a clinical chart audit, 2) current periodontal disease status as determined by clinical examination, and 3) a patient response questionnaire on past professional care and personal oral care habits. Bivariate analyses were performed using a statistical package.

RESULTS

Of the 100 subjects, 74 were diagnosed as periodontal case type IV at the point of referral, of which 29.8% were treatment planned by the periodontist for two or more extractions. Teeth treatment planned for extraction were significant as a function of disease severity (P = 0.0001). Periodontal treatment provided in general dental practices did not vary because of disease severity. The incidence of deep cleanings (scaling and root planing) was reported slightly higher (32.4%) for case type IV than for case type III (26.9%), but this difference was not statistically significant. The average number of cleanings received in the general dental office was less than the standard of care according to the severity of the disease.

CONCLUSION

If one assumes that the data obtained in the Kansas City practices are representative of a larger geographic area, it indicates that dentistry may be failing to address issues of the timely diagnosis of periodontal disease, appropriate treatment, and/or timely referral for treatment.

Demographic Variables Affecting Patient Referrals From General Practice Dentists to Periodontists

BACKGROUND

Within dentistry, a limited body of literature exists regarding the referral relationships between general practitioners (GPs) and specialists. The purpose of this study was to investigate the referral relationship between GPs and periodontists within the state of Virginia.

METHODS

A survey was developed that focused on the demographic variables in the referral relationship between GPs and periodontists. The survey was mailed to 800 dentists throughout the state of Virginia. Descriptive statistics were completed along with multivariate logistic regression analysis comparing the responses with the number of patients referred per month to periodontists.

RESULTS

Female respondents were more likely to refer three or more patients per month to a periodontist than a male respondent (P<0.02). Those dentists who practiced with one other dentist were twice as likely to refer more frequently when compared to solo practitioners or larger group practices (P<0.03). Dentists employing two hygienists were more likely to refer patients than those with fewer hygienists (P<0.02). Those whose practices were >5 miles from the nearest periodontist were more likely to refer patients compared to dentists geographically closer to a periodontist (P<0.02). No other variables had a significant effect on the referral of more patients per month to a periodontist.

CONCLUSIONS

This study indicates that four demographic variables have a statistical influence on the number of referrals per month from a GP to a periodontist. These variables are as follows: female gender, practicing with one other dentist, employing two or more hygienists, and being >5 miles away from the nearest periodontist.

Prevention of periodontal diseases

The ultimate goal of periodontal disease prevention is to maintain the dentition over a lifetime in a state of health, comfort, and function in an aesthetically pleasing presentation. This article focuses on primary and secondary periodontal disease prevention as they relate to gingivitis and periodontitis. Risk assessment, mechanical plaque control, chemical plaque control, current clinical recommendations for optimal prevention, and future preventive strategies are discussed.