Majority of adults experience mild to moderate forms of periodontitis at some point in their lives. The prevalence of this condition is higher among the elderly demographic. Recent data suggests that approximately 10.8% of the adult population worldwide is affected by some form of periodontitis. [12, 13] However, the situation in Nepal is quite different, with a prevalence rate of 47.5%. [14, 15] The higher prevalence of periodontitis in Nepal can be attributed to various factors such as inadequate knowledge regarding proper oral hygiene practices, poor economic status, limited awareness of the importance of oral health, and a lack of accessible oral healthcare facilities and personnel in their region. If left undiagnosed and untreated in its early stages, the prevalence of periodontitis may continue to rise in Nepal.
General dental practitioners (GDPs) are usually the first healthcare professionals to encounter patients with various forms of gingival and periodontal diseases. The knowledge, attitude, and practices of GDPs regarding the diagnosis and management of these conditions have a significant impact on their prevalence and severity. Several studies have been conducted in the past to assess the knowledge, attitude, and practices of GDPs in relation to the diagnosis, management, and referral patterns of gingival and periodontal diseases. [16, 17] The referral of patients to a periodontist is influenced by a range of clinical and non-clinical factors. Clinical factors include the extent, severity, and prognosis of the gingival and periodontal diseases, as well as complex medical histories of the patients. [18, 19]. Nonclinical factors encompass limited undergraduate training, continuing dental education programs, lack of knowledge, etc. [18–20]
In this study, the initial assessment focused on the knowledge of general dental practitioners (GDPs) regarding basic periodontal examination. The majority of participants reported always examining bleeding on probing (138, 57.98%), tooth mobility (178, 78.15%), and gingival enlargement (173, 72.68%) in their routine clinical practice. Additionally, they sometimes examined pocket probing depth (153, 64.28%), furcation involvement (133, 55.88%), mucogingival defects (147, 61.17%), and trauma from occlusion (139, 58.40%). Only a few GDPs did not consider periodontal examination as part of their routine clinical practice. These findings align with a similar study conducted by Priya et al. [21] Majority of participants (189, 79.40%) in this study reported performing scaling and root planning to treat bleeding gums, which is consistent with previously published literature. [18, 21, 22, 23] The participants were also asked about various aspects of gingival bleeding. Most of the GDPs sometimes investigate the causes of gum bleeding (116, 48.70%), refer patients to a periodontist for treatment (147, 61.80%), and always advise patients to maintain oral hygiene to address bleeding gums (234, 98.30%). These results are consistent with the anticipated findings of other studies. [10] Regarding nonsurgical procedures, majority of GDPs performed these procedures themselves and did not call or refer patients to a periodontist, which has also been observed in previous studies. [11, 22, 24, 25]
In terms of surgical procedures, majority of the participants reported occasionally performing minor periodontal surgical procedures, such as gingivectomy (137, 57.56%). However, most GDPs indicated that they never perform other periodontal surgical procedures, including frenectomy/vestibuloplasty, crown lengthening, flap surgery, free gingival autograft, and ridge augmentation. These findings are similar with other studies. [3, 10, 17, 25] The reasons behind this trend could be attributed to a lack of exposure during undergraduate training, insufficient confidence, and limited knowledge to perform such types of periodontal surgeries.
The participants' attitude towards periodontal health, disease, treatment, and referral were assessed using a structured questionnaire consisting of seven items. Nearly all participants (almost 100%) acknowledged the necessity of periodontal referral in routine clinical practice. This finding is consistent with previous research. [10, 18, 25] The majority of GDPs (182, 76.5%) scheduled patient recalls after periodontal therapy for evaluation. Moreover, a significant number of GDPs (182, 76.5%) recognized the need for periodontal re-treatment in their routine practice and proceeded to retreat patients with periodontal diseases after therapy. These findings align with previously published articles. [10, 25] Regarding the factors contributing to the recurrence of periodontal disease, most participants believed that patient-related factors such as lack of maintenance and awareness played a significant role. Additionally, 115 participants (48.3%) attributed the failure or recurrence of periodontal disease after therapy to general dentist factors, including a lack of knowledge, skill, chair-side time, motivation, and awareness. Few GDPs also identified operator factors, such as inadequate preparation before surgery, lack of skill, and time, as potential causes of recurrence. Similar results were reported in a study conducted by Priya et al. [10] The majority of participants in this study believed that the cessation of bleeding, elimination of pockets, reduction in tooth mobility, and increased longevity of teeth were the desirable outcomes of periodontal therapy.
In this study, the majority of general dental practitioners (GDPs) reported always performing full-mouth and subgingival scaling (193, 81.09%), providing advice on proper brushing techniques (205, 86.13%), advising patients to stop harmful habits (212, 89.07%), and offering diet counseling (122, 51.26%) for patients displaying signs of gingival or periodontal diseases. Similarly, they sometimes performed splinting for patients with these conditions (164, 68.90%). These findings align with the information reported in previous literature. [10, 11] If GDPs were unable to perform these procedures, they would typically refer the patients to a specialist periodontist.
Specialist periodontal referral is influenced by various factors, which can impact the referral process. [17] These factors include: complex medical history, previous treatment by a periodontist inability to motivate patient to improve oral hygiene, patient's awareness of periodontal disease, patient's reluctance to undergo periodontal treatment, fees charged by the periodontist, loss of income to the practice if referred, time constraints in the general dental practice, repeated refusal of referral by the patient, lack of training to treat periodontal disease, administrative factors
Dentist-related factors include lack of knowledge, confidence, and exposure among general dental practitioners, as well as limited access to continuing dental education. [1, 17, 20, 25] Periodontist-related factors encompass the age, ethnicity, and sex of the periodontist, as well as the ease of communication for questions or treatment planning, patient feedback, association with a university or research institution, provision of educational events, fee structure, quality of reports, and clinic location. [17]
In this study, the majority of GDPs indicated that they occasionally consult a periodontist for specific periodontal problems, such as the presence of periodontal pockets (143, 60.084%), mobile teeth (150, 63.025%), gingival enlargement (145, 60.924%), periodontal abscess (146, 61.344%), and gingival recession (149, 62.605%). Common procedures performed by periodontists in GDPs' clinics included gingivectomy/gingivoplasty (149, 62.605%), frenectomy/vestibuloplasty (144, 60.504%), crown lengthening (137, 57.563%), and flap surgery (134, 56.302%). These findings align with previously reported articles. [10, 11, 22, 24]