The Perception of General Dental Practitioners and Pediatric Dentists about Orthodontic Knowledge and Proper Referral Patterns for Orthodontic Patients
Manal Rayeq Al Ghanem - BDS
Senior Orthodontist; Ministry of Health of Jordan | Jordanian Board in Orthodontics - Dr.Manalalghanem@yahoo.com
Juman Mohammed Al-Zaben - BDS
Consultant Orthodontist, Orthodontic Clinic, Dental Department; Ministry of Health of Jordan | Jordanian Board in Orthodontics - firstname.lastname@example.org
Manal Rayeq Al Ghanem, Juman Mohammed Al-Zaben. The Perception of General Dental Practitioners and Pediatric Dentists about Orthodontic Knowledge and Proper Referral Patterns for Orthodontic Patients. Smile Dental Journal. 2022;17(2):14-8.
Introduction: Referral to orthodontic clinics mostly comes from general dental practitioners and pediatric dentists. However, inappropriate referrals, in terms of missed early diagnosis of malocclusions or patients not ready for treatment lead to unbalanced orthodontic treatment care, where orthodontists are obliged to give long waiting lists.
Objective of the study: The objective of this study was to: assess the orthodontic diagnostic skills perceived by general dental practitioners and pediatric dentists when referring patients for orthodontic dental care.
Design of the study: A cross-sectional study.
Sample setting & Inclusion Criteria: The study population consisted of all general dental practitioners and pediatric dentists in ministry of Health in Jordan and the study sample consisted of (171) physicians, a questionnaire was distributed to them online.
Results: The respondents were 81.3% of them for (GDPs) and 18.7% for (PDs). The respondents’ genders was 76% Females and 24% Males. The respondents’ Ages was varied from about 38% for (35 – Less than 45), followed by 32.2% for (Less than 35) and 2.9% for 55 and more. The respondents’ perceptions were very close in terms of improving self-esteem, physical attractiveness and reducing teasing, (the P-values respectively=0.151, 0.286, 0.712). Also in terms of reducing caries and periodontal disease (the P-values respectively=0.991, 0.412). However, there was a difference in reference to TMD, and brushing teeth easier (P-value=0.058, 0.044). As for scoring the treatment needed for several malocclusions, there was generally an agreement between general dental practitioners and pediatric dentists. However, there was a high statistical difference for class I, II division1 & 2 (P-value=0.001, 0.046, 0.041), and in terms of spacing (P-value=0.019), where pediatric dentists showed a higher perceived treatment need than general practitioners in referring these type of malocclusions earlier.
Referrals, Treatment need, Pediatric dentists, General dental practitioners Referrals, Treatment need, Pediatric dentists, General dental practitioners.
Orthodontic treatment has become a central part in specialized dental care given from most of the comprehensive health centers and hospitals in Ministry of Health of Jordan. Referral to orthodontic clinics mostly come from general dental practitioners (GDPs) and pediatric dentists (PDs). However, many studies showed that inappropriate referrals, in terms of missed early diagnosis of malocclusions or patients not ready for treatment will lead to unbalanced orthodontic treatment care, where orthodontists are obliged to give long waiting lists.1-4
On the other hand, these studies justified these inappropriate referrals for Lack of Knowledge and improper diagnostic skills for different malocclusions. O’Brien, K. M et al. in 1996 revealed that one reason for an excessive length in the waiting list of new orthodontic patient consultation is the unnecessary referral of patients by general practitioners.5
In a study by Parfitt and Rock3 who surveyed 30 general practitioners for their treatment plan accuracy and referral pattern, only 14% of general practitioner treatment plans agreed with the gold standard.3 In West Sussex, while 52% of dentists were able to correctly identify which type of orthodontic provider they refer to, only 20% of them were able to determine the appropriate time of orthodontic referral.2
The objective of this study was to: assess the orthodontic diagnostic skills perceived by (GDPs) and (PDs) when referring patients for orthodontic dental care.
MATERIALS AND METHODS
The study was registered and ethical approval was granted by ethical committee of Ministry of Health (#:18672).
A questionnaire was developed with reference to previous studies. It consisted of three main parts, the first part was concerned with demographic information for the members of the study sample, the second part was general questions about benefits and risks of orthodontic treatment, and the third part consisted of photos and related questions about orthodontic knowledge and proper referral patterns for orthodontic patients (Fig. 1,2)
Validity of Questionnaire
Before using the questionnaire in the main survey, the questionnaire was presented in its preliminary form to (5) professors of arbitrators specialized in Jordanian Universities, the researchers asked them to express their opinions on the degree of clarity of the clauses, the degree of validity of each paragraph in measuring what was set for measurement, and the degree of accuracy and integrity of the language, as well as any changes to the wording, integration, deletion or addition of paragraphs of the tool. In the light of the observations of the arbitrators, modifications and corrections were made to the language of some paragraphs.
Reliability of Questionnaire
The questionnaire was distributed to a survey sample consisting of (10) dentists, and it was re-applied after two weeks of the first applied, and the Pearson correlation coefficient between the two applies was found, and it amounted to (0.813), which is an appropriate value for the credibility of the study tool.
The study population consisted of all general dental practitioners and pediatric dentists in ministry of Health in Jordan and the study sample consisted of (171) physicians, a questionnaire was distributed to them online.
200 online questionnaires were emailed to the respondents, but only 171 of the study sample responded. The respondents were 81.3% of them for (GDPs), and 18.7% for (PDs) (Fig. 3). The respondents’ genders was 76% Females, and 24% Males (Fig. 4). The respondents’ Ages was varied from about 38% for (35 – Less than 45), followed by 32.2% for (Less than 35), and 2.9% for (55 and more). (Fig. 5)
Comparing the opinions of the two study sample groups (GP, Pediatric Dentists) toward the risks and benefits of orthodontic treatment is shown in (Table 1):
The respondents’ perceptions were very close in terms of improving self-esteem, physical attractiveness and reducing teasing, (the P-values respectively: 0.151, 0.286, 0.712). Also in terms of reducing caries and periodontal disease (the P-values respectively=0.991, 0.412). However, there was a difference in reference to TMD, and brushing teeth easier (P-value=0.058, 0.044).
The second table showed the respondents’ knowledge what extent different Malocclusions need orthodontic treatment (Table 2).
There was a general agreement among the two groups in terms of the diagnosis of different malocclusions. For class I malocclusions, 70.6% of PDs and 38% of GDPs showed that the patients are of a great need. For a Class II division I Malocclusion, 64.7% of PDs and 49.6% of GDPs showed that the patients are of an extremely great need. For class II division 2 malocclusions 61.8% of PDs and 44.5% of GDPs showed that the patients are of an extremely great need. For class III malocclusions 67.6% of PDs and 62.8% of GDPs showed that the patients are of an extremely great need. For patients with deep bite, 47.1% of PDs are of great need while 42.3 %of GDPs showed that the patients are of a moderate need. For patients with an edge to edge overbite, 38.2% of PDs are of moderate need while 46.7% of GDPs showed that the patients are of a great need. For patients with an open bite discrepancy more than 2mm, 38.4% of PDs are of extremely great need while 44.5% of GDPs showed that the patients are of an extremely great need. For a unilateral posterior cross bite, 47.1% of PDs and 39.4% of GDPs showed that the patients are of a moderate need. For a bilateral posterior cross bite, 44.1% of PDs and 50.4% of GDPs showed that the patients are of an extremely great need. For crowding, 50.0% of PDs and 40.9% GDPs showed that the patients are of a great need. For spacing, 55.9% of PDs showed that of moderate need and 42.3% GDPs showed that the patients are of a minimal need. For photos showing average overbite, 52.9% of PDs and 39.4% of GDPs showed that the patients are of a great need. For a normal transverse relation 58.8% of PDs and 59.9% of GDPs showed that the patients do not need any treatment. For a normal alignment 38.2% of PDs showed that patients had a minimal need, while 28.5% of GDPs showed that the patients do not need any treatment.
- In regard to the perceived benefits of orthodontic treatment, the psychosocial variables (improved self-esteem, improved physical attractiveness, and reduced incidents of teasing) received the highest ratings by the groups with no significant differences between them. Dental health factors were rated lower than the psychosocial variables with a significant difference between the groups in terms of the perceived benefit of orthodontic treatment to reduce TMD symptoms, and ease brushing of teeth. These findings were consistent with Aldrees AM et al.‘s study which has the same demographic population and the educational level of Health providers.6
It showed that pediatric dentists, general practitioners, and (to some extent) orthodontists tend to have unrealistic expectations of the dental health benefits of orthodontic treatment. Bollen et al. study identified an absence of reliable evidence describing positive effects of orthodontic treatment on periodontal health.7
Furthermore, Helm et al. showed No relationship between the malocclusion traits and caries prevalence.8
These findings were also addressed by Rock WP et al. and Jayaprakash PK et al.9,10 and indicated that an evidence-based approach to the continuing dental education courses should be implemented to address these perceptions.9,10
- As for scoring the treatment needed for several malocclusions, there was generally an agreement between PDs and GDPs, but the first group showed a higher perceived treatment need, and this is reported in many studies.11-13
In the sagittal malocclusions there’s a high statistical significance between the two groups,in terms of class I, class II divisions 1&2 (P-value=0.001, P-value=0.046, P-value=0.041). However, for class III malocclusions, the two groups have a general agreement about referring this type of malocclusion earlier than other malocclusion, because the parents usually seek for treatment more when their child has a class III.
For transverse, vertical, and alignment problems there was no significant statistically differences between the two groups, except for spacing where there was a statistically difference (P-value=0.019). This indicated a high general agreement between the two groups except for spacing. Surprisingly, PDs perceived need as moderate where GDPs perceived it as minimal. This can be explained that pediatric dentists in general rate perceived treatment need higher than GDPs. Aldrees et al. study1 showed that this may be related to the fact that pediatric dentists were usually the first dental health care professionals to clinically examine the children and they are more oriented toward addressing malocclusal complications as soon as they are observed.
This study was limited by lack of information from dental casts, radiographs, and patient health histories was given to the respondents. So these results cannot be generalized with a clinical setting.
- The pediatric dentists, and general dentistry practitioners, generally perceived psychological treatment need than dental health factors.
- There was agreement among the two groups in regard to the urgency of treatment need indifferent malocclusions in all three planes of spaces except for class III malocclusions and spacing the pediatric dentists have rated higher urgency.
CONFLICT OF INTEREST
The authors have no conflict of interest to declare.
The authors would like to thank Ms. Rania Khorma, Informative Technology employee in Ministry of Health of Jordan for her cooperation and help in the database review and the email communications with the participants.
- de Bondt B, A. I. Referral patterns of Dutch general dental practitioners to orthodontic specialists. Eur J Orthod. 2010;32(5); 548-54. doi:10.1093/ejo/cjp148
- Jackson OA, C. S. Orthodontic referral behaviour of West Sussex dentists. Br Dent J. 2009;207(9). 430-1. doi:10.1038/sj.bdj.2009.979
- Parfitt AA, R. W. Orthodontic Treatment Planning by General Dental Practitioners. British Journal of Orthodontics. 1996;23(4);359-65. doi:10.1179/bjo.23.4.359
- Reddy S, D. K. Orthodontic referrals: why do GDPs get it wrong? Br Dent J. 2016;221(9):583-7. doi:10.1038/sj.bdj.2016.826
- O’Brien, K. M. Do dentists refer orthodontic patients inappropriately? Br Dent J. 1996;132–6. doi:/10.1038/sj.bdj.4809188
- Aldrees AM, T. N.H. Orthodontic treatment and referral patterns: A survey of pediatric dentists, general practitioners, and orthodontists. Saudi Dent J. 2015;27(1);30-9. doi:10.1016/j.sdentj.2014.11.001
- Anne-Marie Bollen, J. C.-C. The Effects of Orthodontic Therapy on Periodontal Health: A Systematic Review of Controlled Evidence. The Journal of the American Dental Association. 2008;139(4).
- Sven Helm, P. E. Causal relation between malocclusion and periodontal health. Acta Odontologica Scandinavica. 1989;47(4):223-8.
- Rock WP, O. K. Orthodontic teaching practice and undergraduate knowledge in British dental schools. Br Dent J. 2002;192(6):347-51. doi:10.1038/sj.bdj.4801371
- Jayaprakash PK, M. P. A survey on orthodontic services provided by general dental practitioners. J Family Med Prim Care. 2019;8(7):2490-5. doi:10.4103/jfmpc.jfmpc_371_19
- Berk, N.B.P. Perception of orthodontic treatment need: opinion comparisons of orthodontists, pediatric dentists, and general practitioners. J. Orthod. 2002;287-91.
- Kapoor D, B. S. Assessment of the Attitude and Knowledge of the Principles and Practices of Orthodontic Treatment Among the Non-orthodontic Specialists and General Practitioner Dentists. JNMA J Nepal Med Assoc. 2018;56(212):766-9. doi:10.31729/jnma.3674
- Yilmaz HN, O. O. Assessment of the Diagnostic Skills of General Dentists in Different Types of Orthodontic Malocclusions. Turk J Orthod. 2021;34(3):189-98. doi:10.5152/TurkJOrthod.2021.20087