‘Attitude and knowledge among Medical Students Towards Collaboration of Dental and Medical Practice: A Cross Sectional Survey in Southern India’

Background: Enhancing oral health care services provided through inter-professional collaboration between medical and dental practitioner is important, and even essential. Purpose of this study is to assess the attitude and knowledge among medical students towards Medical-Dental collaborative practice. Methods: A cross sectional questionnaire survey was done on medical students of 3 rd year, 4 th year and interns of medical colleges in coastal South India. 234 responses obtained and correlated with age, gender and year of study of participants. The questionnaire consisted of 11 questions with 5-point likert scale response to elicit their attitude and knowledge regarding medical-dental collaborative practice. Results: Most of the students agreed that oral health was an integral part of systemic health, but statistically signicant (p<0.05) participants disagreed on attending compulsory rotation in moreover participants did not to active role in motivating dental check-up. 82 % of the medical students are of opinion that dental check-up should be included in the health packages under health insurance. Statistically signicant (p<0.05) difference seen among 3 rd year & 4 th year students, interns and also it was seen that females have given better response towards medical-dental collaboration.

Academic institutions need to enhance curricula to address the global challenges of oral health and local oral health care needs of a population who are more prone to medical emergencies.
In order to achieve greater resource e ciency and upgrade the standard of care and comprehensiveness by reducing duplication and gaps in services, interprofessional collaboration is a main key to success 4 .
All parties will bene t from this improved professional cooperation between medical and dental practitioners and better educate the public. Overlooking underlying health problems while treating a patient is what most dentists do while they focus on the diagnosis and treatment of oral diseases.
Likewise, doctors may fail to notice their patient's oral health problems which could result in initiation of a long-lasting medical illness. Enhancing health care services through inter-professional collaboration between medical and dental practitioner is therefore important, and even essential 5 . Yet there is limited literature on it, an article was published after the First Systemic Health Round Table Discussion to advocate for better medical-dental collaborative practice. Inter-professional collaboration enhances communication and decision-making, enabling a synergistic in uence of grouped knowledge and skills 6 .
Hence the purpose of this study is to evaluate the attitude and knowledge among the medical students towards collaboration between medical and dental practice in South India and to understand the shortcomings and address them with a better strategy.

Methodology:
Ethical approval: Approval was obtained from the Institutional ethics committee (IEC) of Manipal College of Dental Sciences, Mangalore. Necessary permissions and the consent of participants were taken and all methods are in accordance with relevant guidelines and regulations for carrying out the survey.

Study design:
This cross-sectional self-administered questionnaire survey with a minimum calculated sample size of 180 participants for the study was carried out among the 3 rd year, 4 th year students and interns (5 th year) of medical colleges in and around Mangalore, a coastal urban area in the south Indian state of Karnataka. Medical students were invited to participate in the study and they were visited for data collection on a pre informed date.
Statistically calculated sample size of 180 students were needed to obtain valid results for this study. The questionnaire was validated by a medical and dental faculty each. Questionnaire contained 11 objective questions which were pre texted and structured and were in lled in pencil/paper format. Answers were recorded based on 5-point Likert scale (1-strongly disagree, 2-Disagree, 3-Neutral, 4-Agree, 5-Strongly agree). Knowledge and attitude were compared with 3 parameters; Age (below 20 years of age, 21-24 years, above 20 years of age), Gender (Male and female) and Study year (3 rd year, 4 th year, Interns).

Score calculation and interpretation:
For the study to be more statistically valid and comprehensible we calculated the score for each question and statistical analysis done with median of scores received as measure of central tendency and evaluate the statistical signi cance.
The collected data were coded and analysed using statistical package of social sciences (SPSS) version 11.5. Results were expressed as proportion and summary measures (median with inter quartile range) using appropriate tables and gures. For comparison across the groups Mann Whitney U test was employed. A p value of 0.05 was considered as statistically signi cant.

Results:
A total of 250 questionnaires were distributed and 234 responses were obtained from 3 rd year, 4 th year and interns from medical colleges in coastal South India with response rate of 93.6%. Those who returned a blank questionnaire or incomplete questionnaire were excluded. The mean age of the participants being 21.5 years with 58.36% respondents being female and 41.64% males. Out of total respondents, 43.77% were 3 rd years, 39.9% were 4 th years and rest 17% accounted for interns.
There was no statistically signi cant difference in knowledge and attitude based on gender except that female students were signi cantly more (p value-0.00) aware of interprofessional referral practice before elective medical surgeries (Table1). Overall analysis of gender-based difference in responses indicated that females have slightly better knowledge and attitude than males regarding the intended collaboration Most of the students agreed that oral health was an integral part of systemic health with analysis leading to median score of 5, (Table-2) but statistically signi cant difference in attitude of medical students based on study year was seen when asked about attending compulsory rotation in dentistry with senior students showing negative attitude. Almost more than half the participants had adequate knowledge regarding the medical-dental relationship, whereas almost 47% were clueless about the existing relationship, which was assessed by question number 2, 3, 4 and 5. Statistical signi cant difference in knowledge was seen (Table-2) with p value of 0.003, when asked about importance of salivary bio markers. Also, statistically signi cant number of participants had a difference in attitude based on study year with p value of 0.013 when about physician role in motivating their patients for regular dental checkup with senior students showing worse attitude. However, 82 % of the medical students were of the opinion that dental check -up should be included in the health packages under health insurance.
Most students were aware about the possible collaboration but only 61.8% agreed to the foster integral collaboration; 12.8% disagreed, out of which 4% strongly disagree and the rest were unsure. Medical students (61%) gave a median score of 4, and agree upon regular interaction required with dental students to mutually exchange knowledge. Interestingly 25% of them have replied neutral, which again indicates lack of interest with regards to the same.
Statistically signi cant difference based on age was see with p value of 0.014 when asked about relation of HIV patient and dental treatment. Participants belonging to 21-25 years age groups showed lesser knowledge regarding the same.

Discussion
This study was used to evaluate the attitude and knowledge of medical students towards collaboration of medical and dental practice. We included only medical students in the survey as it would suffer a response bias from dental students as participants may simply have positive disposition towards the study objective, as shown by a study which was conducted by Zhang in 2015 7 .
Overall, the medical students showed fairly good attitude and knowledge towards medical and dental collaboration in congruence with the results obtained in the study by Zhang. 7 But analysis of groups within each parameter showed a signi cant difference. Based on year of study, it was found that student from third and nal year had more positive attitude,than the Interns, unlike results obtained by Zhang. 7 More than half the number of participants, particularly the interns did not agree to attend compulsory rotation in dentistry with p value of 0.017, contrary to nding in which Hendricson and Cohen 8 concluded this rotationship not only bene cial but essential.
Although nearly 50% participants had fair knowledge regarding the oral-systemic link, many participants were confused when asked if it was mandatory to undergo an oral check-up before pregnancy. Su cient research has shown that severe periodontal disease in pregnant women predisposes her to a higher risk to deliver preterm and/or low-birth weight new born 10 . Offenbacher 11 found mothers with periodontal disease are at a risk seven times more than the normal. When asked about diabetes and oral health link students seemed to have some vague knowledge regardless of year of study. In addition, previous investigations have established an association between either type 1 or type 2 diabetes and periodontal diseases to the extent that Periodontitis has been called the ''sixth complication of diabetes'' 12,13 . Interestingly analysis among gender revealed statistically signi cant difference with more knowledge among females with regard to questions pertaining to criteria to undergo treatment among HIV patients.
Though it does not provide any supporting evidence to prove poor knowledge, but it indicates the level of confusion among the medical students about HIV patients and dental treatment.
While assessing the attitude, we found signi cant data that junior students advised and motivated their patients to undergo dental check-up regularly, compared to senior students who gave a more of neutral response. One of the reasons for such an attitude from senior students can be because of the concept of social hierarchy which can be due to lack of interprofessional communication and patient management 4 .
In the United States, utilization of oral health care services and the incidence of oral disease are strongly linked to dental insurance coverage 14 .In India though the dental insurance sector has not yet taken off, 40-50% of the medical students strongly feel that dental check-up and some part of treatment must be covered in general health packages.
Around 50-60% participants on average responded positively towards the integral collaboration and interprofessional communication, although 25-30% students were not sure and the rest disagreed to it. Analysis showed that the third and nal year students were more positive than interns which is in contrary to result obtained from study by Zhang et al 7 . The exposure at clinics along with the interest of students affect the perception of oral health and its importance among the medical students, which when applied to Indian scenario the egocentric power relations among healthcare workers which instead of creating new ways, is threatening this interprofessional collaboration 15 .
Student's attitude is associated with factors such as gender, regular dental check-up, and curriculum.
Results of a previous study reported that gender could affect a student's attitude towards medical dental collaboration 9 . Questions pertaining to the attitude towards collaboration such as insurance bene ts for dental treatments received positive response from females than males. When asked about importance of interprofessional communication for exchange of knowledge and better patient care, females gave a greater positive response than males, which can be attributed to higher ego among males 15 .
In clinical practice, Interprofessional continuing education is a useful means of regulating and stabilizing a professional's identity and improving teamwork 4 . Guidelines must be set to improve con dence in provider's ability with regard to cases pertaining to both the elds and have access to updated knowledge about the collaboration between medical and dental practice. Medical and Dental professional body plays an important role here. They can lay guidelines for the indications, timing, protocols, and responsibilities of referral and consultation among physicians and dentists. Patients and the community should be made to understand the relationship between oral and systemic health by means of awareness campaigns. In doing so, National health goals can be achieved only by reducing these kinds of healthcare disparities.

Conclusion
Even though medical students showed fairly positive attitude and knowledge towards dentistry, the analysis within the study groups showed that knowledge and attitude regarding the collaborative practice worsened over the academic years among the medical students.
To break the stereotypes, in clinical practice continuing dental education programs are very useful means to foster collaboration and two-way referral relationship to improving resource e ciency and the standard of care Improvement in MBBS (medical) course curriculum to address the gap in interprofessional management of patients with stress on signi cance of effects of Oral health on general health to instill a sense of con dence and necessity of interprofessional relation among under graduates.

Ethics approval and Consent to participate:
Ethical approval was obtained from the Institutional ethics committee for conducting this questionnaire survey with the reference number-17020.
Written informed consent was obtained from all the participants before lling the questionnaire survey form.

Consent for publication:
Not applicable 3. Availability of Data and materials: The datasets used and analysed for the study can be made available from the corresponding author on reasonable request.