PATIENT’S ORTHODONTIC PROBLEMS AND REFERRAL PRACTICES AMONG GENERAL DENTAL PRACTITIONERS AND NON-ORTHODONTIC SPECIALISTS

Objective : To evaluate the awareness of orthodontic problems and referral practices among general dental practitioners and non-orthodontic specialists practicing in Kingdom of Saudi Methods : Cross-sectional prospective study included general dentists and specialists/consultants of both genders, aged between 22-60 years, practicing General dentistry and as specialist other than orthodontics for 2 or more years. Non-practicing dentists and non-registered dentists were excluded. Data was analysed on SPSS version 21.00. Results : Results revealed that males were 55.5% and general dental practitioners were 44%. It is evident that 53.5% (107) GDPs and 33% (66) non orthodontic specialists practiced orthodontic referral in their practices. Cross-tabulation of variables compared with gender and general dental practitioners and non-orthodontic specialists, using chi-square test, revealed significant p-value of orthodontist referral, but recommendation of orthodontic treatment only after the eruption of all permanent teeth, awareness of tooth extraction for alignment of irregular teeth, and awareness regarding worsening of TMJ problems by orthodontic treatment. Conclusion : It has been concluded that the referral practices of dentists practicing in Kingdom of Saudi Arabia, concerning orthodontic patients, were satisfactory, although awareness regarding orthodontic problem requires unremitting learning and considerate positive progression towards basic orthodontics.


Introduction
Orthodontics deals with facial and dental aesthetics 1 , and correct association between dental and skeletal tissues provide finest aesthetics and functions to the patient 2 .
Awareness of a dentist about the existence of orthodontic problem with their patients is of paramount importance. A dentist should be able to identify dental and skeletal malrelationships. Numerous factors influence orthodontic practices which include personal and practice characteristics of dentists. A study published in 2019 reported that there was a significant difference between the orthodontic care provider and non-orthodontic care provider -general dental practitioners (GDPs) -in terms of knowledge, attitude, and orthodontic needs among two groups of practitioners 3 . Their results pointed out and highlighted that continuous dental education programs and use of information resources play a valuable role in GDP and non-orthodontic specialists' education.
General dental practitioners and even pedodontists are the primary sources of identification and referral of the patient to an orthodontist. Various studies reported that many general dental practitioners provide basic orthodontic treatment and referral to an orthodontist in majority patients 4,5,6 . Another study conducted in India and published in 2016, determining practices of pedodontists for orthodontic referral, revealed that the knowledge and practices of paediatricians are not sufficient 7 . They should be aware of the common understanding of orthodontic problems and develop a habit of referral to an orthodontist. A study conducted to evaluate the basic knowledge and practices of GDPs and non-orthodontist practitioners revealed reduced knowledge and practices 8,9 . Unfortunately, fewer studies determining patient's referral to orthodontists among Saudi dental practitioners, were available 10,11 . Therefore, this study was planned to evaluate knowledge, awareness, attitude and referral practices of dentists and non-orthodontic specialists in Kingdom of Saudi Arabia.

Methods
This cross-sectional prospective study was conducted from a pre-designed questionnaire, which consisted of 22 questions addressing to dentist and non-orthodontic specialists. Samples were recruited through nonprobability convenience sampling.
Inclusion criteria for sample population were: 1. The sample population included General dentists and specialists/consultants of both genders, 2. aged between 22-60 years, Practicing general dentistry or other dental specialty at least 2 or more years.
Exclusion criteria were: non-practicing dentists and non-registered dentists, as well as fresh dental graduates.
The duration of the study was 6 months i.e. from April 2019 to September 2019.
Raosoft software was used to calculate the sample size which was 200 having a margin of error 5%, population size 100, and confidence level 95% and response distribution of 50%.
The participants were asked for verbal informed consent to be included in the study.
All the responses were recorded on a predesigned form by the researchers. The study was carried out on a previously used 11 structured questionnaire containing 22 questions, which were validated after a pilot study. The questionnaires were formulated for the study of the knowledge and attitude of the general dental practitioners and non-orthodontic specialties toward practice of orthodontic treatment. The first part of the questionnaire was designed as to collecting the demographic and other practice-related information, such as specialty and years of experience. Second part consisted of 13 questions, which were framed to study the knowledge of general dental surgeons and non-orthodontic specialties. The questions were of Yes/No type, questions. indicating their knowledge regarding starting age of orthodontic treatment, mixed dentition stage treatment, facial appearance, functional therapy, inclined teeth, extraction of teeth for orthodontic purpose etc. Last part, which consisted of 09 questions (Yes/No type), was prepared to study attitude toward orthodontic treatment, like, diagnostic orthodontic procedures, opinion of orthodontist, giving information to patient about malocclusion when patient comes for the other dental treatment, orthodontic treatment in patients with periodontal problems, orthognathic surgeries.
Statistical analysis was done with the SPSS version 19.0. Statistically significant pvalue was ≤ 0.05. Frequencies and percentages were calculated for qualitative variables.
Cross tabulation was performed using descriptive analysis. A Chi-square test was done to evaluate the association of different qualitative variables with gender and specialty. The pvalue of < 0.05 was considered as significant.

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The results revealed that among questioned dentists and non-orthodontic specialists, females were 45.5% and males were 55.5%. Among specialties, general practitioners constituted the highest percentage (44%), followed by others ( Figure 1).  (Table   1). orthodontic procedures, counselling of patient for orthodontic treatment, and awareness regarding worsening of TMJ problems by orthodontic treatment (Table 2).

Discussion
This study was carried out to evaluate the awareness of patient' orthodontic problem and referral practices among general dental practitioners and non-orthodontic specialists, practicing in Kingdom of Saudi Arabia.
In this study, general dental practitioners constituted the highest percentage i.e. 44% followed by other specialists. This is inconsistent with the study conducted by AlBaker AM et al 13  Recommendation of orthodontic treatment only after the eruption of all permanent teeth is another significant factor in both cross-tabulations. Orthodontic treatment depends upon the age at which patient reports and seeks orthodontic treatment.
Treatment after the age of eruption of all teeth has the advantage of patient cooperation and compliance, but limited treatment outcome 17,18 . It also depends upon the emergence and eruption of teeth. A study published in 2016 in Angle orthodontics revealed that the age of mixed dentition period is increased in children born in the era of 1999-2000 as compared to the children born in the era of 1976-1985. Girls showed more advanced eruption compared to boys 19 . Therefore, the patient should be thoroughly examined and treatment outcomes should be discussed after considering all factors for the orthodontic referral.

Consideration of skeletal malocclusions in patients with incompetent lips and inclined
teeth is another factor that showed a significant influence of patient referral. It has been considered that patients with inclined teeth and incompetent lips are more likely to have skeletal malocclusion and treatment of these patients along with orthodontic fixed appliance therapy in combination with orthognathic surgery will dramatically modify the treatment outcomes and save overall treatment time. Patients with incompetent lips and inclined anterior teeth should be thoroughly investigated and referred to the orthodontist for further treatment 20 .
A study published in the Saudi medical journal in 2014, evaluated different factors of lip incompetency among Saudi children 21 . Their study revealed that lip incompetence was not only related to bimaxillary protrusion, pointing to other skeletal, dental and soft tissue factors, which also play an important role in lip competency.
GDPs are aware of tooth extraction significance for the alignment of irregularly positioned teeth. However, extraction of permanent teeth carried out to create space and relieve crowding could be a factor that demotivates patients to seek orthodontic treatment.
A study conducted on Yemeni children revealed that only 2% of children had undergone orthodontic consultation and treatment, the extraction of teeth being one of the factors that deferred orthodontic treatment 22 . Another study revealed that almost 100% of nonorthodontic specialists and 87.5% GDPs are aware of significance the extraction of teeth has for orthodontic treatment 23 .
Another important factor is awareness of possible worsening of TMJ problems by orthodontic treatment. It is considered that orthodontic treatment could worsen a preexisting TMJ problem. In our study, this factor appeared significant, showing a general belief that GDPs and non-orthodontic specialists consider worsening of TMJ problem after orthodontic treatment 24 . However, a study published in 2015, conducted at Oulu University Hospital, revealed that treatment of severe malocclusion leads to improvement in overall VAS score of facial and TMJ related pain 25 .
In our study, we compared and determined awareness and referral practices of dentists for orthodontic patients reported to dental clinics and compared different variables connected with referral practice. The variables which showed significant p-value were the recommendation of orthodontic treatment for patients with periodontal problems, conduction of diagnostic orthodontic procedures, counselling of patient for orthodontic treatment, and awareness regarding worsening of TMJ problems by orthodontic treatment.
The limitations of the study were a small sample size and a cross-sectional design. Other factors should also be considered for evaluation of referral for orthodontic treatment, i.e.
It is recommended that awareness programs, talks, and seminars should be arranged for GDPs and non-orthodontist specialists to enhance their understanding of orthodontics.
The use of social media should be made effective, so that patients seek early orthodontic treatment and consultation.

Conclusion
We could conclude that the referral practices for orthodontic patients of dentists practicing in Kingdom of Saudi Arabia were satisfactory, although awareness regarding orthodontic problem requires unremitting learning and considerate positive progression towards basic orthodontics.