Is There A Difference In Operative Dentistry Services Offered By Teaching Versus Non-Teaching Dentists In Karachi?

INTRODUCTION

The city of Karachi has an estimated population of 20 million individuals. Although, the number of private dental practitioners are on a rise but still yet to cater for the population needs. To some extent, the vacuum of dental care has been filled up by the academic dental centers. The academic practices are the undergraduate and the post graduate dental institutions of the city. Its interesting to note that there are nearly 12 such institutions with over 800 active dental operatories in this city providing dental care to thousands of individuals on annual basis. Thus, it can safely be assumed that there are two strata of dental care provision in Karachi: the private dental clinics and the dental colleges/ hospital. We hypothesized that the provision of Operative Dentistry services varies with type of the

clinical setup as the clinicians in private practice are subjected to the pressure of time and cost effectiveness.The academic dentists on the other hand, have an additional responsibility of teaching and training the young breed of dentists. This may affect their clinical volumes of quality of service. With the backdrop, its imperative to explore the status dental care provision in the city.

OBJECTIVE

To compare the pattern of Operative Dentistry services offered by the teaching and non teaching dentists in Karachi, Pakistan.

OPERATIONAL DEFINITIONS

1. Teaching dentist: Dentists employed in academic institutions as faculty members, fellows or post graduate students were labeled as teaching group.
2. Private Practitioners: Dentists who were not associated with any academic institution and are full time practitioners were considered in this group.
3. Pattern of Operative Dentistry service: clinical decision making, preferences of restorative materials and selection of techniques in dental conservation.

METHODOLOGY

It was a cross sectional study conducted at seven undergraduate and five post graduate dental institutions and their attached clinical settings in Karachi and selected private Dental Practices in different parts of Karachi.

Inclusion Criteria: Dentists who were registered with Pakistan Medical & Dental Council (PMDC) and have at least completed one year internship after graduation and are engaged in practice, teaching or both.

Exclusion Criteria: Dentists who are not active in practice or retired were excluded. Sampling technique: The names and contact information of the practitioners were obtained from the Office of the Pakistan Dental Association Karachi division (last updated in 2007). There are about 250 dentists in the academic settings and 750 in private settings. Stratified random sampling was done to select the study subjects, considering the academic and private practice settings as two distinct strata. Sample size: We calculated the sample size to test if there is a significant difference in the proportion of dentists using GIC (Glass ionomers based restorations) for primary teeth at 5% significance level and 80% power. We assumed (using our clinical judgment and experience) that in teaching group 70% and in the nonteaching group 50% dentists may use GIC. The sample size turned out to be 67 in teaching group, while in non-teaching group 201. To adjust for refusal, we inflated the sample size by 10% to get the sample of 75 in the teaching and 220 subjects in the non-teaching group.

Ethical Approval: The study protocol was approved by the Aga Khan University ethical Review Committee (Ref # 573-Sur/ERC-06). The informed consent of the participants was taken.

Data Collection Tool: A structured, self-administered questionnaire (written in English) regarding preferences, selection of materials and techniques used in providing

Operative Dentistry. The questionnaire had three parts:

• First part dealt with Demographics (independent variables)
• Second part had 28 questions on Operative Dentistry practice (response variables).

Data Collection Method: Questionnaires were given to the study population by hand. A reminder via telephone was made in case of no response after 2 weeks. A second reminder after four weeks of distribution was made to collect the maximum number of questionnaires. To ascertain the information reliability, we repeated 3 (10%) questions at the end of the of the study questionnaire.

Data Analysis: SPSS 19.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. From the demographic section, means and standard deviations of the quantitative variables and proportions for the categorical variables were determined. The response variables in the study are about the preferences in material and clinical technique selection. These responses are measured on nominal or ordinal scale.

Independent samples test was applied to compare continuous variables such as age and experience of the participants. Chi Square test (or Fishers exact test) was applied to test if clinical preferences and pattern of services are different between dentists in academic settings than those in private practices. Mann-Whitney U test was applied to compare the two groups for ordinal scale responses. P-value less than 0.01 were considered as statistically significant. Kappa statistics was applied to assess the agreement between the initial responses and the repeated questions.

RESULTS

The total number of participants in our study was 168 out of which 71 (42.3%) participants were teaching dentists while 97 (57.7%) were private practitioners. Around 30 (out of 70) in the teaching and 40 (out of 97) in the non-teaching group were females. The response rate in the teaching group was 94.6% (71 out of 75) while in the practitioners group, it was 44.1% (97 out 220). Both groups were comparable with respect to the age (p-value 0.1) and professional experience (p-value 0.07). Teaching and non teaching dentists have statistically significant differences regarding their interest in clinical specialties (p-value 0.003).

Both groups stated that amalgam is their material of choice for Class I and Class II restoration in molars and premolars. However, both preferred composite in premolars Class I preparation. In class V teaching dentists selected composite while most practitioners preferred Glass ionomer (p<0.001)

Use of rubber dam was scarce, inlays and onlays were infrequently done by the both groups. Private practitioners were more inclined towards dentine pins and gold crowns placement while teaching dentists.

Table 1: Descriptive Statistics and Comparison of Age and Experience of Participants in the Two Groups (n=168)

Independent samples test was applied to compare the two arithmetic means.

Table 2: Specialty of Interest according to Group Status (n=168)

Chi Square (Fisher’s Exact test) of proportions at 0.05 level of significance

Table 3: Comparison of dentists regarding directly placed restorations (n=168)

Chi Square test (or Fisher’s Exact test) were applied. Level of significance was set at 0.01

Table 4: Comparison regarding Operative Dentistry Clinical Procedures (n=168)

Mann-Whitney U test was applied to see the difference between the two groups for ordinal responses. Level of significance was set at 0.01

Table 5: Comparison of Teaching and Non -Teaching dentists, Reasons for Not Employing Clinical Procedures

Chi Square test (or Fisher’s Exact test where needed) were applied. Level of significance was set at 0.01. T refers to teaching group while P is the practice group.

Table 6: Comparison of Teaching and Non-Teaching dentists regarding Crowns (n=168).

Chi Square test (or Fisher’s Exact test where needed) were applied. Level of significance was set at 0.01.

reported frequent use of amalgam bonding, retraction cords and topical anesthetic administration (p<0.001) The reliability of the information obtained in our study ranged between acceptable to good (65-72%).

DISCUSSION

Although the participants in both the study groups were similar in age and professional experience (table 1) but their clinical interests were highly variable. Both the teaching and non-teaching dentists selected general dentistry, operative dentistry and Endodontics as their areas of interest. Pediatric Dentistry and Periodontics were found to be the least attracted fields. The probable reason of clinician not inclined towards these specialties is lack of training centers and faculty in these areas 1, 2.

There were significant differences between the two study groups for their decision making for direct restoration in Class I and II cavity preparations. Private practitioners were mainly confined to amalgam as the preferred material but selected composite resins as the alternatives. Amalgam remained the preferred restorative for academic dentists but their choice of alternatives was broad. In addition to composites, they did select GIC and RMGIC too. Similarly, major differences were seen in Class V scenario as well. Our results were in agreement with Burke

Its a high time for teaching and non-teaching dentist to engage themselves in a life long commitment of continuing education to predictably meet the point of care and to routinely carry out good-quality dentistry.

STRENGTHS & LIMITATIONS

This study involves both strata (academic institutions and as well as private practices) thus, it provides the

information from the two sides. The relatively poor response rate from the practitioner group (97 out of 201 or 48.25%) appears bad but upon exploring into the causes of this low response rate, its obvious that busy practitioners are not interested in completing questionnaires during business hours. A response rate of 26.3% was recorded by Haj -Ali 14 in USA, Mjor 15 had response rate of 51% while Forss 16 received a response rate of 53.6% from dentists in similar studies. This suggests that its not uncommon for practicing dentists to give low response rate. In this context, our response rate of 44.1% does not appear that bad. Since the information of non responding practitioners was not available, so we could not explore any further in this direction.

However, this non-response bias has the potential to affect the study results.

In comparison to practitioners, the teaching dentists showed an excellent compliance (94%) in responding to the questionnaires probably because they are familiar to research activities and therefore, more complacent and open in participation.

CONCLUSIONS

There are significant differences between the teaching and practitioner groups regarding operative

dentistry. The use of rubber dam, gold crowns, amalgam adhesives and retraction cord were not satisfactory for both the groups.

RECOMMENDATIONS

Emphasis should be given on Operative Dentistry at an undergraduate curriculum. A system of revalidating the dental practice license on completing required numbers of CME should made a mandatory requirement.

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